Utilization Review RN
Part time 0.7 FTE – Evening Shift at Providence, Swedish Medical Center. We offer a comprehensive benefits package beginning on day one of employment.
Description
The Utilization Review (UR) Nurse owns clinical reviews for admission, concurrent, and retrospective utilization management. The role ensures appropriate admission status, data tracking, evaluation, and reporting in compliance with regulatory and reimbursement requirements. The UR Nurse actively participates in process improvement initiatives, collaborates with multiple departments, and remains current on payer policies and accreditation standards.
Responsibilities
Collaborate and consult with departments and providers to confirm medical necessity indicators.
Conduct clinical reviews of medical records to determine admission status and ongoing medical necessity.
Identify, report and refer cases requiring secondary review to Case Management leadership, Medical Director, or Physician Advisor.
Facilitate provider documentation to reflect patient severity of illness and risk accurately.
Maintain collaborative relationships with providers, case management, revenue cycle, and payer compliance teams.
Submit clinicals, enter authorizations, and conduct appeals for concurrent and hospital stays.
Work with compliance, contracting, revenue cycle, and physician advisors on medical necessity matters.
Uphold applicable state and federal laws and reimbursement system requirements.
Provide concurrent support to providers to optimize reimbursement and ensure compliant documentation.
Stay current in utilization review practices, reimbursement modalities, and legal issues.
Generate workflow reports to analyze productivity, quality concerns, utilization patterns, and denial trends.
Develop, implement, evaluate, and revise initiatives to improve quality, continuity, and cost-effectiveness.
Provide thorough documentation per department standards.
Coordinate education and training on utilization management for staff and health care providers.
Mentor and orient new staff.
Escalate issues to Case Management or leadership in a timely manner.
Equipment / Technology
PC: data entry, Windows, Microsoft Word, Excel, PowerPoint, Internet Explorer; email; EPIC and other case management software.
General office equipment: telephones, voicemail, fax machines, scanners, printers.
Qualifications
Bachelor's degree in Nursing (BSN) from an accredited school of nursing.
Washington Registered Nurse License upon hire.
Minimum 3 years of registered nursing experience in a clinical setting.
Preferred Qualifications
ACM or CCM certification upon hire.
At least 1 year of case management experience.
Equal Opportunity Employer
Providence is an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings free from unlawful discrimination and harassment on any basis protected by law.