Providence Health & Services RN Care Coordinator Quality Medical Management in Texas
Providence St. Joseph Health is calling a RN Care Coordinator Quality Medical Management to our location in Beaverton, OR. This postion will be remote and can sit in the footprint of Providence in the states of AK, WA, OR, CA, TX, and MT.
We are seeking a RN Care Coordinator Quality Medical Management to provide administration of medical management programs that include: prior authorization, concurrent hospital and skilled nursing review, appeals and grievance, delegation, medical policy development and medical claims audits. These programs are developed to manage medical expense, determine medically appropriate services and define clinical criteria for decision making. This includes retrospective review of claims and other data, as well as care coordination and discharge planning.
Reporting on productivity and service standards to demonstrate effectiveness and efficiency of programs.
Functioning as a liaison and problem solver with multiple departments and providers.
Defusing conflicts and negotiating solutions in potentially volatile situations.
Managing multiple priorities efficiently and effectively.
Integrating and using data and literature from various sources.
Maintaining quality program standards while meeting productivity targets.
In this position you will have the following responsibilities:
The position of RN Care Coordinator may include responsibilities for one or more of the following functions:
Functional area: Medical Review (Concurrent Review and Prior Authorization):
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.
Develop and maintain a thorough knowledge of Interqual criteria and concurrent review policies, procedures and approved resources.
Review requests for prior authorization following all lines of business criteria, health plan medical policy criteria and department policies and procedures, including required timelines.
Functional area: Medical Claims Audit:
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.
Effectively communicate the findings from review activities to providers, members and internal staff as outlined in the department policies and procedures.
Track and report determinations, savings, turnaround time, and medical information related to the review criteria.
Functional area: Medical Policy and Criteria:
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.
Collaborate with physicians and medical directors regarding pending policy decisions and communicate policy criteria to all departments, both internally and externally, on-line provider resources, handbooks and newsletters.
Facilitate and prepare documents for the Medical Policy Committee and Technology Assessment Committee.
Act as liaison to other departments providing information and decisions to improve operational efficiencies and communication with members, providers and staff.
Functional Area: Clinical Appeals:
Maintain thorough knowledge of the appeal process following regulatory and accrediting requirements.
Maintain positive working relationships and serve as a clinical resource for the Appeals and Grievance department.
Maintain timeliness of the appeal review and all levels of the review process and required communication to the member, including an explanation of the decision rationale and a description of the review process.
Maintain program quality by completing routine audits, following department policies and procedures. Examples include: denial file audits, documentation standards, letters, turnaround times, interrater audits. Prepare audit reports for review, including corrective action plans.
Identify quality of care issues forwarding them to Quality Management for review.
Provide training and expertise on medically related issues across the organization.
Maintain a thorough knowledge of utilization management and cost containment strategies, member and providers contracts, all utilization management programs,workflow systems and personal computer software applications as appropriate.
Required qualifications for this position include:
5 years Clinical nursing experience
Experience working with physicians in the collaboration and management of patient care
Current license as a registered nurse (RN) in the state of Oregon
Preferred qualifications for this position include:
Bachelor's Degree in Nursing or health education
Utilization review, discharge planning and/or managed care experience
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 comprehensive, best-in-class benefits to our caregivers. For more information, visit
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 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.
Job Category: Case Management
Other Location(s): Montana, California, Washington, Oregon, Texas, Alaska
Req ID: 328818