Providence Health & Services RN Care Coordinator – Quality Medical Management in Beaverton, Oregon
Providence is calling a RN Care Coordinator – Quality Medical Management to Providence Health & Services in Beaverton, OR.
In this position you will have the following responsibilities:
Perform onsite and telephone concurrent review of hospitalized members, skilled nursing, acute rehabilitation or other services, following Quality Medical Management (QMM)policies and procedures and documentation standards.
Initiate and/or participate in discharge planning for hospitalized members, including case conferences and care coordination upon discharge.
Review claims pended for medical review or for specified claims audits, following department policies and procedures. Claims reviews are done for medical necessity, billing accuracy and appropriate coding.
Maintain accurate and timely documentation, as outlined in the department policies and procedures. This includes approval and all denial letters and additional communications as indicated by lines of business.
Provide oversight of delegated utilization management activities to ensure compliance with regulatory and accrediting requirements.
Perform audits, approvals, corrective action and ongoing training to the delegates, as outlined in the policies and procedures.
Develop medical policy and criteria to assure all policies and criteria are reviewed annually. Research and prepare documents needed for medical policy development, new technology assessment, new application of existing technology, drugs, and devices using resources such as the provider community, professional associations and organizations, technology assessment organizations, Medline literature searches, and regulatory agencies.
Maintain files that document medical policy/procedure decisions, revisions, and annual reviews.
Required qualifications for this position include:
Current license as a registered nurse in the state of Oregon.
5 years of clinical nursing experience with preference given to experience in utilization review, discharge planning and/or managed care.
Experience working with physicians in collaboration and management of patient care.
Ability to type and use a computer to perform the specific functional duties, including documentation.
Preferred qualifications for this position include:
- Bachelors degree in nursing or health care
About Providence in Oregon
As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.
The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple,
"Providence will provide the best care and service to every person, every time."
Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.
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: Health Plans
Req ID: 195451