Providence Health & Services RN Care Coordinator - Utilization Management in Everett, Washington
Providence is calling a Registered Nurse Care Coordinator- Utilization Management to the Utilization Management Team at Providence Health & Services in Everett.
We are seeking an RN Care Coordinator- Utilization Management to oversee utilization management and review of patients care delivery while in the hospital, as well as provide clinical reviews and denial appeals where appropriate either during admission or post discharge.
This is a Full Time 1.0 FTE (40 hours per week), Day shift position. Working every other weekend is required.
In this position you will:
Review the electronic medical records to perform admission screens on new admits utilizing Interqual criteria to determine medical appropriateness of the hospital admission and to address appropriate patient class determination.
Perform continued stay reviews on current patients and communicate clinical information to payers in a timely manner such that the patient’s hospital days are authorized.
Manage concurrent denials and facilitate peer to peer physician reviews.
Demonstrate age specific patient care considerations for the population served.
Coordinate with discharge planning through active organization and monitoring of the patient care process to provide continuity of care cost effectiveness.
Required qualifications for this position include:
Nursing Degree/ diploma upon hire
Bachelors of Nursing (BSN) or higher required within five (5) years of hire
Experience as an RN in an acute care setting in the last 5 years or recent utilization management experience.
Current RN license in Washington State.
Ability to perform concurrent and post medical necessity reviews to determine appropriateness of level of care documented and provided using nationally accepted criteria, State and Federal guidelines, evidenced-based research, and predictive determinations for insurance denials.
Ability to assess clinical documentation and make recommendations regarding the most appropriate route of resolution, up to and including verbal/written efforts of appeal.
Ability to construct and document a succinct, assertive, and fact-based clinical summary to support medical necessary criteria.
Ability to critically think, problem solve and make independent decisions supporting the litigation process, including interactions with payer representatives, arbitrators/mediators, physicians and client hospital case managers.
Ability to coordinate with patient care, physicians, health plans, and Revenue Cycle departments to enhance and defend the accuracy of the charge and coding processes.
Preferred qualifications for this position include:
Utilization review or case management experience.
Experience with Interqual or Milliman Criteria.
Utilization Management certification.
Case Management certification.
Care management, medical insurance or discharge planning experience.
About the hospital you will serve:
Providence Regional Medical Center Everett in Everett, WA is the state’s most award-winning hospital for medical care; having received the HealthGrades Distinguished Hospital Award for Clinical Excellence four years in a row. Our new state-of-the-art 12 story hospital tower and the implementation of an electronic medical records system will significantly enhance our patient’s experience throughout the continuum of care.
The hospital is located in Snohomish County on the Sound and close to the mountains, so outdoor activities such as snow skiing, kayaking, and golfing are at your doorstep. The communities in Snohomish have all the comforts and appeal of small towns, with historical districts, beautiful homes, interesting boutiques, and unique restaurants, yet the city life of Seattle and Bellevue are just 30 minutes south, while the cosmopolitan city of Vancouver, BC lies only 2 hours north.
We offer a full comprehensive range of benefits - see our website for details
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence Health & Services is a not-for-profit Catholic network of hospitals, care centers, health plans, physicians, clinics, home health care and services guided by a Mission of caring the Sisters of Providence began over 160 years ago. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Case Management
Req ID: 231878