Swedish
Utilization Review RN – Swedish
Part time 0.7 FTE
Evening Shift
Fantastic benefits and compensation package offered by Providence that begin on your first day of employment. Join us, and find out how many ways we offer you the chance to focus on what really matters – our patients.
Job Description The Utilization Review (UR) Nurse blends a strong clinical background with extensive knowledge of Utilization Management (UM) and medical necessity. This individual supports the UM program by developing and maintaining efficient processes for determining appropriate admission status based on regulatory and reimbursement requirements of commercial and government payers. The UR nurse performs admission, concurrent and retrospective UR reviews and ensures accurate data tracking, evaluation, and reporting. The role actively participates in process improvement initiatives and collaborates with multiple departments and multidisciplinary staff.
Responsibilities
Collaborate and consult with appropriate departments and providers to ensure medical necessity indicators are met.
Provide a clinical review of the medical record to determine an admission status type for a patient.
Conduct concurrent clinical reviews to assess ongoing medical necessity.
Identify, report cases and problems appropriate for secondary review to Case Management leadership, the Medical Director or Physician Advisor.
Facilitate appropriate provider documentation to reflect patient severity of illness and risk.
Maintain collaborative relationships with providers, case management staff, clinics, Revenue Cycle team, and Payer Compliance team.
Submit clinicals, enter authorizations for concurrent and hospital stays after discharge, and conduct appeals as applicable.
Collaborate with providers, compliance, contracting, revenue cycle, internal and external Physician Advisors; work with other departments for medical necessity matters.
Work in accordance with applicable state and federal laws and reimbursement system requirements.
Facilitate accurate, compliant clinical documentation by providing concurrent support to providers to optimize reimbursement.
Stay current in UR to be informed of reimbursement modalities, resources, and legal issues that affect patients and providers.
Provide leadership with workflow reports to analyze productivity, quality concerns, utilization patterns, and denial trends.
Participate in the development, implementation, evaluation, and ongoing revision of initiatives to improve quality, continuity, and cost-effectiveness.
Provide clear and thorough documentation based on established department standards.
Coordinate education and training for staff and other health care providers regarding the utilization management process.
Provide orientation and mentoring to new staff.
Escalate issues to Case Management team or leadership in a timely manner.
Equipment Competency
PC: Data entry, Windows, Microsoft Word, Excel, PowerPoint, Internet Explorer; Email; EPIC and other Case Management software.
General Office Equipment: telephones, voice‑mail, fax machines, scanners, printers.
Required Qualifications
Bachelor's Degree Nursing (BSN) from an accredited school of nursing.
Washington Registered Nurse License upon hire.
3 years Registered nursing experience in a clinical setting.
Preferred Qualifications
ACM or CCM certification upon hire.
1 year Case management experience.
Compensation Pay Range: $51.43 - $79.84 per hour. Additional compensation may include shift differentials, standby/on‑call, overtime, premiums, and bonus opportunities.
Benefits Providence offers a comprehensive benefits package including retirement 401(k) with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, paid parental leave, vacations, holidays, health issues, voluntary benefits, and well‑being resources.
Job Details
Requisition ID: 396124
Company: Swedish Jobs
Job Category: Health Information Management
Job Function: Revenue Cycle
Job Schedule: Part time
Job Shift: Evening
Career Track: Nursing
Department: 3900 SS CASE MANAGEMENT
Address: WA Seattle 1730 Minor Ave
Work Location: Swedish Metropolitan Park East–Seattle
Workplace Type: On-site
Seniority level: Mid‑Senior level
Employment type: Full‑time
Job function: Health Care Provider
Industries: Hospitals and Health Care
Equal Opportunity Employer Providence is proud to be an Equal Opportunity Employer. We are committed to providing a workplace free from unlawful discrimination on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, marital status, genetic information, or any other prohibited basis.
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Fantastic benefits and compensation package offered by Providence that begin on your first day of employment. Join us, and find out how many ways we offer you the chance to focus on what really matters – our patients.
Job Description The Utilization Review (UR) Nurse blends a strong clinical background with extensive knowledge of Utilization Management (UM) and medical necessity. This individual supports the UM program by developing and maintaining efficient processes for determining appropriate admission status based on regulatory and reimbursement requirements of commercial and government payers. The UR nurse performs admission, concurrent and retrospective UR reviews and ensures accurate data tracking, evaluation, and reporting. The role actively participates in process improvement initiatives and collaborates with multiple departments and multidisciplinary staff.
Responsibilities
Collaborate and consult with appropriate departments and providers to ensure medical necessity indicators are met.
Provide a clinical review of the medical record to determine an admission status type for a patient.
Conduct concurrent clinical reviews to assess ongoing medical necessity.
Identify, report cases and problems appropriate for secondary review to Case Management leadership, the Medical Director or Physician Advisor.
Facilitate appropriate provider documentation to reflect patient severity of illness and risk.
Maintain collaborative relationships with providers, case management staff, clinics, Revenue Cycle team, and Payer Compliance team.
Submit clinicals, enter authorizations for concurrent and hospital stays after discharge, and conduct appeals as applicable.
Collaborate with providers, compliance, contracting, revenue cycle, internal and external Physician Advisors; work with other departments for medical necessity matters.
Work in accordance with applicable state and federal laws and reimbursement system requirements.
Facilitate accurate, compliant clinical documentation by providing concurrent support to providers to optimize reimbursement.
Stay current in UR to be informed of reimbursement modalities, resources, and legal issues that affect patients and providers.
Provide leadership with workflow reports to analyze productivity, quality concerns, utilization patterns, and denial trends.
Participate in the development, implementation, evaluation, and ongoing revision of initiatives to improve quality, continuity, and cost-effectiveness.
Provide clear and thorough documentation based on established department standards.
Coordinate education and training for staff and other health care providers regarding the utilization management process.
Provide orientation and mentoring to new staff.
Escalate issues to Case Management team or leadership in a timely manner.
Equipment Competency
PC: Data entry, Windows, Microsoft Word, Excel, PowerPoint, Internet Explorer; Email; EPIC and other Case Management software.
General Office Equipment: telephones, voice‑mail, fax machines, scanners, printers.
Required Qualifications
Bachelor's Degree Nursing (BSN) from an accredited school of nursing.
Washington Registered Nurse License upon hire.
3 years Registered nursing experience in a clinical setting.
Preferred Qualifications
ACM or CCM certification upon hire.
1 year Case management experience.
Compensation Pay Range: $51.43 - $79.84 per hour. Additional compensation may include shift differentials, standby/on‑call, overtime, premiums, and bonus opportunities.
Benefits Providence offers a comprehensive benefits package including retirement 401(k) with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, paid parental leave, vacations, holidays, health issues, voluntary benefits, and well‑being resources.
Job Details
Requisition ID: 396124
Company: Swedish Jobs
Job Category: Health Information Management
Job Function: Revenue Cycle
Job Schedule: Part time
Job Shift: Evening
Career Track: Nursing
Department: 3900 SS CASE MANAGEMENT
Address: WA Seattle 1730 Minor Ave
Work Location: Swedish Metropolitan Park East–Seattle
Workplace Type: On-site
Seniority level: Mid‑Senior level
Employment type: Full‑time
Job function: Health Care Provider
Industries: Hospitals and Health Care
Equal Opportunity Employer Providence is proud to be an Equal Opportunity Employer. We are committed to providing a workplace free from unlawful discrimination on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, marital status, genetic information, or any other prohibited basis.
#J-18808-Ljbffr