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Utilization Review RN at Providence St. Joseph Health
Last updated: September 05, 2024
Job Listing
| Title | Utilization Review RN |
|---|---|
| Company | Providence St. Joseph Health |
| Location | Seattle, WA |
| Description |
Description Remote - Utilization Review RN On call/Per diem The Utilization Review (UR) Nurse has a strong clinical background blended with a well-developed knowledge and skills in Utilization Management (UM), medical necessity and patient status determination. This individual supports the UM program by developing and maintaining effective, efficient processes for determining the appropriate admission status based on regulatory and reimbursement requirements of commercial and government payers. The UR nurse is responsible for performing admission, concurrent and retrospective UR related reviews and functions to ensure that appropriate data is tracked, evaluated and reported. This individual actively participates in process improvement initiatives, working with multiple departments and multi-disciplinary staff. This role requires current and accurate knowledge regarding commercial and government payers as well as accreditation regulations/guidelines/criteria related to UM. Providence caregivers are not simply valued - they're invaluable. Join our team at Swedish Shared Services and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them. For direct patient care roles: Performs and maintains currency of essential competencies as required by specific area of hire and populations served. Collaborates and consults with appropriate departments and providers as needed to determine that medical necessity indicators are met. Provides a clinical review of the medical record to determine an admission status type of a patient. Conducts concurrent clinical reviews to assess ongoing medical necessity. Identifies, reports cases and problems appropriate for secondary review to Case Management leadership, the Medical Director or Physician Advisor. Facilitates appropriate provider documentation to accurately reflect patient severity of illness and risk. Maintains collaborative relationships with providers, case management staff, clinics, Revenue Cycle team, and Payer Compliance team. Responsible for submitting clinicals, entering authorizations of both concurrent and hospital stays after discharge. Conducts appeals as applicable. Collaborates with providers, compliance, contracting, revenue cycle, internal and external Physician Advisors. In addition, works with other departments as needed for medical necessity matters. Works in accordance with applicable state and federal laws as well as with the unique requirements of reimbursement systems. Facilitates accurate, compliant clinical documentation by providing concurrent support to providers to optimize reimbursement. Stays current in UR to be informed of reimbursement modalities, resources as well as clinical and legal issues that affect patients and providers of care. Provides leadership with needed workflow reports to analyze productivity, quality concerns, utilization patterns, and denial patterns/trends. Participates in the development, implementation, evaluation, and ongoing revision of initiatives to improve quality, continuity, and cost-effectiveness. Provides clear and thorough documentation based on established department standards. Coordinates education and training for staff and other health care providers regarding utilization management process, including but not limited to: reimbursement patterns, trends, changes in regulations, and strategies. Provides orientation and mentoring to new staff. Escalates issues to Case Management team or leadership in a timely manner. Must demonstrate competency to safely and/or accurately operate the following equipment: PC: Data entry, Windows, Microsoft Word, Excel, PowerPoint, Internet Explorer; E-mail; EPIC and other |
| Citation |
United States Department of Labor Employment and Training Administration (DOLETA) Minnesota Department of Employment & Economic Development (DEED)
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