Job Information

Providence RN Care Coordinator - Utilization Management in Everett, Washington

Description:

Care Coordinator Utilization Management (RN)

The Care Coordinator - Utilization Management (RN) will 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.

Job Duties:

  • Reviews the electronic medical record to perform admission screens on new admits utilizing nationally accepted, evidence-based criteria (Interqual or Indicia) to determine medical appropriateness of the hospital admission and to address appropriate patient class determination:

  • Pre-admission review is performed prior to patient admission and the appropriate patient class is assigned and validated using Interqual or Indicia criteria and supported by a physicians documentation or secondary physician reviewer.

  • Assesses the appropriateness of patient placement using designated admission/discharge criteria.

  • Collaborates with ED clinical treatment team to identify non-medical admits (social admits) for referral to ED Case Managers for PAUSE pathway to prevent inappropriate admission, admit patients to the right level of care, early referral to community providers and governmental agencies, referral to PT/OT and financial counseling for timely assessment of patient needs, and involve family and community case management on date of presentation to the ED.

  • Coordinates with discharge planning through active organization and monitoring of the patient care process to promote continuity of care cost effectiveness:

  • Discharges are reviewed and monitored for effective patient management, cost effectiveness, and appropriate length of stay.

  • Follows patients from admission through discharge and coordinates with discharge planner any specific care needs.

  • Demonstrates age specific patient care considerations for the population served:

  • Demonstrates application of knowledge, skills, and behaviors in the physical, motor/sensory, cognitive, psychosocial, patient and family education areas based on age specific care competency assessment tool.

  • Provides information to physicians, hospital staff, family, community care providers, and patients, as appropriate, to facilitate coordination of clinical activities:

  • Staff and family are oriented and educated regarding the process and requirements.

  • Patients move through the hospital continuum of care in an appropriate time frame and with patients receiving the right care at the right time.

  • Performs 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.

  • Assesses clinical documentation and makes recommendations regarding most appropriate route of resolution. up to and including verbal/written efforts of appeal.

  • Constructs and documents a succinct, assertive, and fact based clinical summary to support medical necessity criteria. Demonstrates 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.

  • Performs continued stay reviews on current patients and communicates clinical information to payers in a timely manner such that the patient’s hospital days are authorized:

  • Cases are reviewed in a timely manner and insurance authorizations are obtained and documented for the patient’s stay

  • Coordinates with patient care, physicians, health plans, and Revenue Cycle departments to enhance and defend the accuracy of the charge and coding processes.

Qualifications:

Required Qualifications:

  • Bachelor's Degree in Nursing (BSN).

  • Must obtain a Bachelor’s degree in Nursing or higher within five (5) years of hire

  • Any previously agreed upon effective date for obtaining a Bachelor’s degree in nursing between individual and facility will remain in effect

  • Any collective bargaining contract with specific time frames for obtaining a Bachelor’s degree in nursing will supersede the above point and will remain in effect

  • Exceptions will be considered on a case-by-case basis at each facility by the most senior administrative nursing leader in consultation with the Human Resources leader

  • Current Registered Nurse (RN) license in Washington State

  • Experience as an RN in an acute care setting within the last five (5) years, OR recent Utilization Management experience

Preferred Qualifications:

  • UM Certification

  • Case Management Certification

  • Utilization review or case management experience

  • Experience with Interqual or Milliman Criteria

  • Care Management, medical insurance or discharge planning experience

Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities.

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 Epic EMR 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 — http://www.providenceiscalling.jobs/rewards-benefits

We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit

https://www.providenceiscalling.jobs/rewards-benefits/

Our Mission

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.

About Us

Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. 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: Full-time

Shift: Day

Job Category: Case Management

Location: Washington-Everett

Req ID: 353097