Kern Family Health Care · 1 day ago
Utilization Management Clinical Auditor and Trainer RN
Bakersfield, CA
Part-time
Onsite
Mid, Senior Level
$45.02/hr - $57.41/hr
5+ years expKern Family Health Care is dedicated to improving the health status of its members through an integrated managed health care delivery system. The UM Clinical Auditor and Trainer RN is responsible for reviewing Utilization Management policies, performing audits, and providing training to clinical staff to ensure compliance and improve operational efficiency.
Health CareHospitalNon Profit
Responsibilities
Maintains knowledge of covered benefits for all programs
Shares information as necessary with appropriate UM Clinical Staff, Population Health Management and Health Education, Quality Improvement, Enhanced Care Management or Community Support Services
Keeps current with California Children’s Services benefits and guidelines for coordination of services
Train other UM staff as appropriate regarding use of all platforms as it relates to UM processes
Maintain an effective, efficient, and confidential filing system both manual and electronic to allow easy retrieval and re-filing of department information
Develop and implement staff training for new and existing employees
Responsible for written and verbal communication to promote timely coordination of care and dissemination of KHS policies and procedures
In coordination with the UM Auditor and Analyst, perform audits of performance of UM Clinical Intake Coordinators and summarize and report the results of the audit to UM Management for process improvement
Perform periodic audits of inpatient and outpatient clinical decisions for appropriateness and accuracy of documentation
Assists in data collection and compilation, of various committee and quarterly reports
Maintains the confidentiality of records and reports for both the membership of KHS and the contract providers
Promote coordination with KHS Medical Director(s), Pharmacy and other departments and community partners, as appropriate, in making sound clinical decisions
Summarize and prepare necessary production reports for management
Performs other job-related duties as required
Adheres to all company policies and procedures related to employment and job Responsibilities
Qualification
Required
Registered Nurse with an active, current, unrestricted California license
Minimum of two (2) years full-time clinical experience in acute care, community health setting, public health nursing or chronic disease management required
Minimum of three (3) years' experience in utilization review required
Strong knowledge of acute chronic care nursing principles, methods and common treatments
Strong knowledge of common human diseases and usual and customary methods of treatments
Demonstrated knowledge of medical terminology
Ability to effectively evaluate medical records to determine appropriateness and necessity of care
Demonstrated knowledge of health care delivery systems
Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individual at all levels both inside and outside of KHS
Ability to use tact and diplomacy to diffuse emotional situations
Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards
Intermediate skills in Word and Excel with basic ability to enter data into and navigate through a database
Demonstrated ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, KHS business or employee information and make no disclosure of such information except as required in the conduct of business
Demonstrated ability to commit to and facilitate an atmosphere of collaboration and teamwork
Self-directed, with proven ability to work independently with minimum supervision
Demonstrated ability to multi-task in an interrupt-driven environment and complete assignments on a timely basis
Strong attention to detail; work accurately and at a reasonable rate of speed
Compliant with KHS policies and procedures; performs the job safely and with respect to others, to property, and to individual safety
Preferred
Bachelor's Degree from an accredited school or equivalent in Nursing, Nursing Education, Health Administration, or related healthcare field is strongly preferred
Prior experience in providing training, education, and auditing preferred
Company
Kern Family Health Care
Kern Health Systems, known as Kern Family Health Care, was established in 1993 as a managed care health plan, and is the largest health plan in Kern County.
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Emily Duran
Chief Executive Officer
Alan Avery
Chief Operating Officer
Recent News
2025-01-07
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