Registered Nurse/Clinical Documentation Specialist

START DATE: **(Currently) Non Negotiable 5/25 Start****MUST have Oregon Licensure in hand, cannot wait for pending license**Role: Fully Remote Part Time Clinical Documentation Specialist RN PositionNBO: 0 HoursCerts Required: BLS, RN, ***OREGON LICENSURE IN HAND*** (Please do not submit RN without Oregon Licensure)Education Preferred: MSNExperience Required: 5 Years of Clinical ExperienceExperience Preferred: 2 years of Medical Case Management; 2 years experience in managed care or in workers' compensation insurance.General Summary:The MCO Clinical Reviewer is accountable for utilization management activities including evaluation of appropriateness and medical justification of health services for MCO eligibles. The position has specific focus on researching, developing, and communicating implementation of Medical Policies, including facilitating Medical Policy Committee work. In addition, the position is responsible for providing medical treatment reviews, case management, and treatment interventions the promote cost effective medical care and early return to work in workers' compensation cases. The position identifies and coordinates opportunities for Continuous Quality Improvement projects as well as provider profiling, benchmarking, and provider education.DUTIES:- Diffuses conflicts and negotiates solutions in potentially volatile or legally sensitive situations.- Relates quality of care with cost effectiveness and develops medical management strategies to reach this objective.- Researches, integrates and analyzes data from multiple sources, synthesizing problem statements and issues.- Seeks input from providers and insurers as needed.- Interacts with multiple departments and providers to problem solve and create solutions that focus on efficiency and quality of care.- Managing health care resources while creating positive interpersonal relationships with workers, insurers, providers and facilities.- Reprioritizing work in a very fast paced environment.- Identification of potential liability situations and implementing strategies to minimize risk to the plan.Essential Functions:- Identifies need for and completes process of developing medical policies and related protocols and criteria, including obtaining final committee approval.- Establishes and maintains a process for regular and timely updating of criteria, treatment protocols, and medical policies.- Performs prospective review of requests for health services, utilizing existing policies and criteria.- Consults with physicians, medical directors, or physician committees regarding requested health services, or appropriateness of services which have already been rendered, or on medical policy issues including interpretation or revision of existing documents.- Identifies, researches, or refers potential quality of care issues. Provides oversight for data gathering and analysis.- Is liaison with Health Plan Utilization Management and Care Management teams.- Retrospectively reviews treatment and makes necessary interventions with medical providers who do not follow treatment protocols, medical rules, or program requirements.- Identifies new or existing program components that need to be developed or revised and initiates appropriate action.- Provide data collection and analysis of provider profiling data and make necessary interventions or training plans that target outlier providers.- Provide medical consultation to non-medical MCO staff as well as focused training to MCO clients where needed.- Tracks all disputed surgical cases, prepares detailed litigation reports, coordinates with MCO attorney and records outcomes.- Applies sound medical principles in case management, medical decision-making, and in developing medical policies and criteria.- Acts as triage for Comp Care Management referrals and provides direct case management where needed.- Identifies and refers cases needing catastrophic case management.- Assists in responding to all general customer service calls.- Codes medical diagnoses and procedures, entering information in data management system. Enter data accurately into U/QM information system, and on paper as needed, to document review findings and decisions.- Maintains timely and accurate review of requests for medical services including reporting of productivity and service standards.- Participates in department team building and committee work.- Actively seeks to improve knowledge and skills by participating in ongoing education and training, literature reviews, networking with professional organizations and colleagues.- Reviews and monitors provider offices, providers and providers' medical record documentation. Assists providers in setting up quality improvement programs within the clinic. Acts as liaison between the MCO and clinic in matters of utilization, quality and access.- Protects confidential and privileged documents, reports and information. Develops standards for communication with many entities with consideration of legal and ethical principles.