Providence Health & Services RN - Care Coordinator Utilization Management - Utilization Management and Clinic in Everett, Washington
Providence is calling a Registered Nurse Care Coordinator, Utilization Management (0.75 FTE, Day Shift) to the Utilization Management and Clinic Team at Providence Health & Services in Everett, WA.
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.
In this position you will:
Reviews the electronic medical record to perform admission screens on new admits utilizing the Interqual criteria to determine medical appropriateness of the hospital admission and to address appropriate patient class determination: • Admission reviews are performed within 24 hours of the patients admission and the appropriate patient class is assigned and validated using Interqual criteria and supported by a physicians documentation or secondary physician reviewer.
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.
Management of concurrent denials and facilitating peer to peer physician reviews: • Clear communication and documentation of notification of all denial information from payers. • Set up peer to peer MD review, by the end of the shift as needed.
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.
Required qualifications for this position include:
Bachelor's Degree Nursing (BSN). Must obtain a Bachelor’s degree in Nursing or higher within (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.
Experience as an RN in an acute care setting within the last 5 years, OR recent Utilization Management experience
Current Registered Nurse (RN) license in Washington State.
Preferred qualifications for this position include:
Utilization review or case management experience
Experience with Interqual or Milliman Criteria
Care Management, medical insurance or discharge planning experience
1 year Experience with behavior health and detox clientele
UM Certification preferred.
Case Management Certification preferred.
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 an electronic medical records system 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 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
Req ID: 322066