Position Summary:
Under general supervision of the Director Quality Management, provides utilization review and case management for
patients referred for inpatient and outpatient care to other healthcare facilities. Minimizes fragmentation in the healthcare
system with a focus in coordinating transitions in care by tracking, monitoring and evaluating referrals and obtaining
preauthorization when needed. Uphold the principles of WIHCCs Vision, Mission, and Value Statements. Maintains
confidentiality of all privileged information at all times.
This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.
Essential Duties & Responsibilities:
-Maintains regular attendance and punctuality.
-Monitors external referral activities set by PRC, providing quarterly reports to ensure the department is on track to
meet necessary measures.
-Provides case management for patients needing referred care from pre-admission to post discharge.
-Works with the patient, family and an interdisciplinary team; develops a care and service delivery plan based on
needs of patient, available provider, and financial resources.
-Conducts appropriate concurrent and retrospective reviews on referred care to patients to determine the
appropriateness of admission, procedures, and the necessity of continued hospital care.
-Determines medical necessity and appropriateness of level of care using Centers for Medicare & Medicaid Services
(CMS) approved criteria for inpatient and outpatient referred care encounters.
-Checks the severity of illness, intensity of service, and discharge criteria on referred patients.
-Refers appropriate cases to the Chief Medical Officer for medical review.
-Screens all referrals for alternate resources and works closely with Business Coordinator and Contract Health Services
to maximize the use of alternate resources for referred care payment, protecting CHS funds for those patients who do
not qualify for alternate resources.
-Certifies the acute hospital level length of stay for CHS payment and WIHCC utilization purposes.
-Determines if services are being delivered as planned and are meeting needs; reassesses, at appropriate intervals, to
determine if the patients condition or situation has changed, and revises goals and plan of services accordingly.
-Works collaboratively with other departments to coordinate patient needs before discharge, discharge planning
activities and continuity of care.
-Serves as an advocate for the patient and their families.
-Provides in-service training to medical providers/PRC staff to enhance communication.
-Upholds all principles of confidentiality and patient care to the fullest extent.
-Adheres to all professional and ethical behavior standards of the healthcare industry.
-Adheres to WIHCCs Personnel Policies and Procedures, departmental policies, rules, and regulations.
-Interacts in an honest, trustworthy and dependable manner with patients, employees, visitors, and vendors.
-Possesses cultural awareness and sensitivity.
-Maintains compliance with all Human Resources requirements.
-Performs other duties as assigned.
Minimum Qualifications:
Graduate of accredited school of nursing. Must be licensed as a Registered Nurse in a State, the District of Columbia, or
Puerto Rico. Certification in Case Management preferred. Three years clinical experience and one year of experience in
utilization management, discharge planning, case management. Bilingual skills in English and Navajo language preferred.
Must maintain a valid unrestricted and insurable drivers license. Must successfully pass a background investigation and
maintain suitable requirements for a Child Care position. This position is considered as a Child Care position, which
requires a satisfactory background check investigation and is subject to the requirements of the Indian Child Protection
and Family Violence Prevention Act, as amended (henceforth referred as the ICPFVP Act).
Knowledge, Skills, Ability:
-Knowledge of the Managed Care Model of healthcare services delivery including utilization review, the use of review
criteria, clinical pathways and practice guidelines, discharge planning and case management.
-Knowledge of federal, state and private agency review requirements and regulations.
-Knowledge of and sensitivity to cultural and language differences.
-Knowledge of strong work ethics in the workplace.
-Knowledge of basic application of confidentiality.
-Knowledge of basic computer skills, e.g. Outlook, Word, Excel, PowerPoint.
-Skills in decision-making and independent judgment.
-Skills in creative problem solving and leadership.
-Ability to be flexible and use above average tact when dealing with people.
-Ability to be dependable in attendance and job performance.
-Ability to meet attendance, overtime (if necessary), and other reliability requirements of the job.
-Ability to accept and learn from feedback.
-Ability to effectively communicate both in written and verbal.
-Ability to provide exemplary customer service at all times.
-Ability to interact positively with others and possess great interpersonal skills.
-Ability to multitask and perform well under pressure.
-Ability to have self-confidence.
-Ability to be a great team player.
-Ability to accept and learn from supervisor/peer critique.
-Ability to be flexible and adaptable to the changing needs of the organization.
Physical Demands:
While performing the duties of this job, the employee regularly is required to walk; sit; use hands to finger, handle, or
feel; reach with hands and arms; and talk or hear. The employee frequently is required to stand; climb or balance; and
stoop, kneel, crouch, or crawl. The employee frequently is required to taste or smell. The employee must occasionally lift
and/or move up to 25 pounds.
Work Environment:
Work is performed in an office setting or outdoor work environment with a moderate noise level. Work environment may
involve exposure to physical risks, such as blood borne pathogens and operating dangerous equipment or working with
chemicals. Evening and/or weekend work may be required. Extended hours and irregular shifts may be required.