Kepro is a rapidly growing national quality improvement and care management organization. We work to ensure that over 20 million people receive the right care, at the right time, in the right setting. Kepro is seeking resumes for a highly experienced professional.
Utilization Review Lead
Coordinates activities of the nurse reviewers to successfully meet contract deliverables. Assists in meeting contract deliverables within budgetary parameters. Utilizes clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements, critical thinking and decision making skills to determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA, URAC and other regulatory standards.
- Assures accuracy and timeliness of all applicable review type cases within contract requirements.
- Assesses, evaluates and addresses daily work load and queues; adjusts work schedules daily to meet the workload demands of the department.
- Analyzes productivity of nurse reviewers.
- Identify nurse reviewers orientation and continuous learning needs and in collaboration with the Manager, develops and implements plans to address those identified learning needs.
- In collaboration with Manager, responsible for the quality monitoring activities including identifying areas of improvement and plan implementation of improvement areas.
- Maintains current knowledge base related to review processes and clinical practices related to the review processes; functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns.
- Functions as providers liaison and contact/resource person for provider customer service issues and problem resolution.
- Performs all applicable review types as workload indicates.
- Foster positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building in order to facilitate the review process.
- Attends training and scheduled meetings and for maintenance and use of current/updated information for review.
- Cross trains and perform duties of other contracts within Kepro to provide a flexible workforce to meet client/customer needs.
The list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary from time to time.
- Active unrestricted RN, or other applicable State and/or Compact State clinical license per contract requirements.
- Graduation from an accredited Diploma, Associates or Bachelors Degree Program.
Knowledge, Skills, Abilities
- Knowledge of InterQual criteria strongly preferred.
- Knowledge of current NCQA/URAC standards strongly preferred.
- Knowledge of the organization of medical records, medical terminology, and disease process required.
- Strong clinical assessment and critical thinking skills required. Medical record abstracting skills required.
- Excellent verbal/written communication skills required.
- Ability to work in a team environment.
- Flexibility and strong organizational skills needed.
- Must be proficient in MS Office and internet/web navigation.
- Minimum 3 years of clinical experience in an acute or med-surgical environment required.
- Minimum of 2 year UR and/or Prior Authorization or related clinical experience.
- For BH Programs: Minimum 3 years direct behavioral/mental health experience in a clinical setting or other applicable State and/or Compact State clinical experience or license per contract requirements.
- Previous workload management experience strongly preferred.
Mental and Physical Requirements
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will be made as required by law in an attempt to enable an individual with a disability to perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time; key and/or control objects; interact extensively with internal and external customers; occasionally lift and/or move objects weighing up to 10 pounds; and occasionally travel within the state.
Kepro offers challenging careers, excellent benefits and opportunities for advancement. For consideration, please submit resume and cover letter with salary requirements. Only those candidates identified for an interview will be contacted. No Phone Calls Please. Visit our website at www.Kepro.com for more information on the Kepro Family of Companies.
EOE AA M/F/Vet/Disability
Kepro is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.