Providence is calling a Registered Nurse Care Coordinator- Utilization Management to Providence Regional Medical Center Everett in Everett, WA. We are seeking a compassionate and caring RN Care Coordinator to oversee utilization management and review of patients care delivery while in the hospital and provide clinical reviews and denial appeals where appropriate either during admission or post discharge.
This is an on-call, variable shift position.
In this position you will:
- Review the electronic medical record to perform admission screens on new admits utilizing the Interqual criteria to determine medical appropriateness of the hospital admission and to address appropriate patient class determination.
- Perform continued stay reviews on current patients.
- Management of concurrent denials and facilitating peer to peer physician reviews.
- Facilitate coordination of clinical activities.
- Coordinate with discharge planning through active organization and monitoring of the patient care process to promote continuity of care cost effectiveness.
Required qualifications for this position include:
- Current Registered Nurse (RN) license in Washington State.
- Bachelor's of Science Degree in Nursing (BSN).
- Experience as an RN in a acute care (hospital) setting within the last 5 years or recent Utilization Management experience.
- 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.
- Care Management, medical insurance or discharge planning experience.
- Utilization Management and/or Case Management Certification.
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 people of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.
Providence Health & Services is the third largest not-for-profit health system in the United States. Providence employs more than 82,000 caregivers (employees) across a five-state area; AK, WA, MT, OR, and CA. Our facilities include 34 hospitals, 600 physician clinics, senior services, supportive housing and other health and educational services. 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.
Schedule: On Call
Job Category: Case Management
Req ID: 148488