utilization management rn

Humana

<div>
 
 Become a part of our caring community
 
 
 
 The Utilization Management Registered Nurse uses clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations. You will report to the Manager of Utilization Management and serve as a member of the One Home/Home Solutions Utilization Management team. This team manages post-acute care services. These services include Skilled Nursing Facility (SNF), Home Health, and Durable Medical Equipment (DME). The team's goal is to ensure members receive the appropriate level of care in the most appropriate setting.
 
 
 
 As a Utilization Management Registered Nurse
 
 
 
 <ul>
 <li>
 You will use clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations.
 </li>
 <li>
 Using established medical criteria, you will make determinations based on information provided by the attending physician and other care providers
 </li>
 <li>
 You will complete request determinations within established processing time frames. (i.e. 10 reviews per day?)
 </li>
 <li>
 You will communicate with providers, members, or other parties to facilitate care and treatment.
 </li>
 <li>
 You will help deliver coordinated care for our members
 </li>
 <li>
 You will understand department, segment, and organizational strategy and operating goals, including their linkages to related areas.
 
 
 </li>
 </ul>
 
 Required Qualifications
 
 
 
 
 Use your skills to make an impact
 
 
 
 <ul>
 <li>
 Must hold Compact Registered Nurse (RN) license in your state of residence
 </li>
 <li>
 Greater than one year of clinical experience as a RN in a hospital, SNF, Home Health, or acute care setting.
 </li>
 <li>
 Must be passionate about contributing to an organization focused on improving consumer experiences
 
 
 </li>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 Previous experience in utilization management/utilization review for a health plan or acute care setting
 </li>
 <li>
 Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual.
 </li>
 <li>
 Experience working in a fully remote, metrics-focused role
 </li>
 <li>
 Experience as an MDS Coordinator or discharge planner in an acute care setting
 </li>
 <li>
 Experience as an RN for a Medicare Certified Home Health agency
 </li>
 <li>
 Health Plan or Medicare / Medicaid Experience
 </li>
 <li>
 Call center or triage experience
 </li>
 <li>
 BSN or bachelor's degree in a related field
 
 
 </li>
 </ul>
 Additional Information
 
 
 
 Work-at-Home Information
 
 
 
 To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
 
 
 <ul>
 <li>
 At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
 </li>
 <li>
 Satellite, cellular and microwave connection can be used only if approved by leadership.
 </li>
 <li>
 Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
 </li>
 <li>
 Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
 </li>
 <li>
 Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
 
 
 </li>
 </ul>
 Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
 
 
 
 Scheduled Weekly Hours
 
 
 
 40
 
 
 
 Pay Range
 
 
 
 The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
 
 
 $71,100 - $97,800 per year
 
 
 This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
 
 
 
 Description Of Benefits
 
 
 
 Humana, Inc. and its affiliated subsidiaries (collectively, &ldquo;Humana&rdquo;) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
 
 
 
 About Us
 
 
 
 About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health &ndash; delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.
 
 
 
 Equal Opportunity Employer
 
 
 
 It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
</div>

Utilization Management Registered Nurse

Advanced Health Coordinated Care Organization

<div>
 We are currently hiring a
 
 Part-time
 
 
 REMOTE Utilization Review Nurse!
 
 If you are a licensed nurse with excellent critical thinking skills, have experience in acute care settings and utilization review, and value being part of a team that makes a difference, you may be the right person for the position!
 
 Apply today!
 
 
 
 
 Classification:
 
 NON-EXEMPT |
 
 Status &amp; Schedule:
 
 PART-TIME, 20-HRS/WEEK, GENERALLY MONDAY &ndash; FRIDAY, BUT MAY INCLUDE ADDITIONAL HOURS TO MEET THE NEEDS OF THE POSITION
 
 
 
 Location:
 
 REMOTE, LOCAL TO OREGON STRONGLY PREFERRED
 
 
 
 Work Location:
 
 OR, CA, AZ, TX, FL
 
 
 
 Salary:
 
 $35.29 - $47.37/HOURLY
 
 
 
 Department:
 
 MEDICAL SERVICES/UTILIZATION REVIEW |
 
 Reports to:
 
 DIRECTOR OF MEDICAL SERVICES |
 
 Supervision Exercised:
 
 NON-SUPERVISORY
 
 
 
 JOB PURPOSE: Utilization Review Nurse
 
 
 
 The Clinical Review Nurse is responsible for providing clinically efficient and effective utilization management. Reviews prior authorization requests for appropriate care and setting by following evidence based clinical guidelines, medical necessity criteria and health plan guidelines. Reviews and applies hierarchy of criteria to all referral and preauthorization requests from the PCP's and specialists that require a medical necessity determination. Is involved in assuring that the patient receives high-quality cost-effective care. Uses sound clinical judgement and managed care principles in the coordination of care. Prepares any case that does not meet medical necessity guidelines for medical appropriateness of procedure, service, or treatment for review with the Physician Reviewer for a decision.
 
 
 
 QUALIFICATIONS, EDUCATION, And EXPERIENCE
 
 
 
 <ul>
 <li>
 Nursing degree from an accredited nursing program
 </li>
 <li>
 Unrestricted Oregon RN license
 </li>
 <li>
 Experience with a similar population in health plans or managed care
 </li>
 <li>
 Experience administering OHP, Medicare benefits or utilization review highly preferred.
 
 
 
 </li>
 </ul>
 
 ESSENTIAL RESPONSIBILITIES: Licensed Utilization Review
 
 
 
 <ul>
 <li>
 Maintains clinical expertise and knowledge of scientific progress in nursing and medical arena and incorporates this information into the clinical review and care coordination processes
 </li>
 <li>
 Performs clinical review for appropriate utilization of medical services by applying appropriate medical necessity criteria guidelines
 </li>
 <li>
 Authorizes healthcare services in compliance with contractual agreements, Health Plan guidelines and appropriate medical necessity criteria
 </li>
 <li>
 Provides accurate and timely documentation within internal system supporting rational of decision based on clinical review
 </li>
 <li>
 Identifies members who are appropriate for care coordination programs and collaborates with the Medical Management team for care coordination of the member's needs along the continuum of care
 </li>
 <li>
 Meets timeliness standards for referral and prior authorization activities
 </li>
 <li>
 Sends appropriate notifications for Third Party Liability (TPL) and/or possible Stop Loss
 </li>
 <li>
 Forward relevant information of members requiring special interventions to Advanced Health
 </li>
 <li>
 Participate in quality and organizational process improvement activities and teams when requested
 </li>
 <li>
 Assist in audit preparation as directed
 </li>
 <li>
 Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
 </li>
 <li>
 Handle confidential information and materials appropriately and maintains a secure work area
 </li>
 <li>
 Maintains the confidentiality of all company procedures, results, and information about patients, contracts, and all other proprietary information regarding company business.
 </li>
 <li>
 Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
 </li>
 <li>
 Handle confidential information and materials appropriately and maintain a secure work area
 </li>
 <li>
 Other duties as assigned
 
 
 
 </li>
 </ul>
 
 ESSENTIAL RESPONSIBILITIES: ORGANIZATIONAL TEAM MEMBER
 
 
 
 <ul>
 <li>
 Participate in quality and organizational process improvement activities and teams when requested
 </li>
 <li>
 Support and contribute to effective safety, quality, and risk management efforts by adhering to established; policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities
 </li>
 <li>
 Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner
 </li>
 <li>
 Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization
 </li>
 <li>
 Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors, by consistently exceeding the customer&rsquo;s expectations
 </li>
 <li>
 Recognize new developments and remain current in [position&rsquo;s expertise] best practice standards and anticipate organizational modifications
 </li>
 <li>
 Advance personal knowledge base by pursuing continuing education to enhance professional competence
 </li>
 <li>
 Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
 </li>
 <li>
 Represent organization at meetings and conferences as applicable
 
 
 
 </li>
 </ul>
 
 KNOWLEDGE, SKILLS, And ABILITIES
 
 
 
 <ul>
 <li>
 Knowledge of OHP program requirements, benefit package, eligibility categories, and Oregon Division of Medical Assistance Program (MAP) rules and regulations preferred
 </li>
 <li>
 Knowledge of ICD, CPT, and HCPCS codes
 </li>
 <li>
 Proficient in Milliman Clinical Guidelines (MCG)
 </li>
 <li>
 Strong attention to detail
 </li>
 <li>
 Ability to think and work independently with minimum supervision
 </li>
 <li>
 Provide critical attention to detail for accuracy and timeliness
 </li>
 <li>
 Ability to manage multiple tasks and remain flexible in a dynamic work environment
 </li>
 <li>
 Ability to report to work as scheduled, and willingness to work a flexible schedule when needed
 </li>
 <li>
 Proficient in Microsoft Office Suite and Windows Operating System (OS)
 </li>
 <li>
 Training in or awareness of Health Literacy, Poverty Informed, Systemic Oppression, language access and the use of healthcare interpreters, uses of data to drive health equity, Cultural Awareness, Trauma-Informed Care, Adverse Childhood Experiences (ACEs), Culturally and Linguistically Appropriate Service (CLAS) Standards, and universal access
 </li>
 <li>
 Knowledge and understanding of how the positions&rsquo; responsibilities contribute to the department and company goals and mission
 </li>
 <li>
 Knowledge of federal and state laws including OSHA, HIPAA, Waste Fraud and Abuse
 </li>
 <li>
 Awareness and understanding of equity, diversity, inclusion, and the equity lens: ability to analyze the unfair benefits and/or burdens within a society or population by understanding the social, political, and environmental contexts of policies, programs, and practices
 </li>
 <li>
 Excellent people skills and friendly demeanor
 </li>
 <li>
 Critical thinking skills of using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems
 </li>
 <li>
 Attention to detail and organization skills
 </li>
 <li>
 Ability to handle stress and sensitive situations effectively while projecting a professional attitude
 </li>
 <li>
 Ability to communicate professionally, both conversing and written
 </li>
 <li>
 Ability to work with diverse populations and interact with people of differing personalities and backgrounds
 </li>
 <li>
 Sensitive to economic considerations, human needs and aware of how one&rsquo;s actions may affect others
 </li>
 <li>
 Ability to organize and work in a sensitive manner with people from other cultures
 </li>
 <li>
 Poised; maintains composure and sense of purpose
 
 
 
 </li>
 </ul>
 
 WORKING CONDITIONS
 
 
 
 This position must have the ability to remain in a stationary position, occasionally move about inside the office to access office machinery, printer, etc., frequently communicate and exchange accurate information.
 
 
 
 Work Condition:
 
 Remote Work Environment
 
 
 <ul>
 <li>
 Employee generally works within a remote work from home environment.
 </li>
 <li>
 Travel may be required on occasion.
 </li>
 <li>
 Hours of operations and specific staff scheduling may vary based on operational need.
 
 
 
 </li>
 </ul>
 
 Exposed to:
 
 
 
 <ul>
 <li>
 Employee is responsible for maintaining a safe work environment that is conducive to successful productivity and work output.
 </li>
 <li>
 Machines, equipment, tools, and supplies used: Constantly operates a computer or other office productivity machinery or software, such as fax, copier, calculator, multi-line telephone system, or scanner.
 </li>
 <li>
 May answer a high volume of telephone calls, complete documentation, and use computer programs to either obtain or record information.
 
 
 
 </li>
 </ul>
 
 Multiple Duties:
 
 Must be able to work under conditions of frequent interruption and be able to stay on task.
 
 
 This job description is intended to provide only basic guidelines for meeting job requirements. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of DOCS Management Services employees. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.
</div>

REMOTE Utilization Review Nurse - Managed Care

Sentara

<div><div>Sentara Medical Group Clinical Administration is now hiring a Full-time RN Integrated Care Manager.
Hours: 36 hours weekly, dayshift
Location: Remote in Virginia Beach, VA
Overview
Responsible and accountable for the provision and facilitation of comprehensive care coordination services and quality outcomes for patients across the continuum. Promotes effective utilization and monitoring of health services, collaborates and communicates with the healthcare team and patient/caregiver to manage care and transitions. Develops and/or implements a comprehensive care plan based on assessment and evaluation of patient/caregiver needs. Functions in one of the following practice settings: Acute Care, Service Lines, Ambulatory/Community-based, Home Health, and Long-Term Care.
Education
<ul><li>Diploma RN/ADN/BSN/MSN</li>
</ul>Certification/Licensure
<ul><li>RN License - Virginia/Compact/Multistate</li>
<li>Basic Life Support (BLS) required within 90 days from hire</li>
</ul>Experience
<ul><li>RN Nursing experience 3 years required</li>
<li>Case Management experience 3 years preferred</li>
<li>Previous experience with the pediatric population preferred</li>
</ul>Keywords : Integrated Care Manager, RN, Case Manager, Talroo-RN, Monster</div></div>

RN Integrated Care Manager

Asante

<div><div><div>Req #: 24661 
Entity: Asante Rogue Regional Medical Center 
Location: Medford OR 
Department: Case Management 
Shift: Variable Schedule Days 
Union Position: No 
FTE: 0.000001 
Schedule: On Call 
Salary: $23.28 - $32.02 depending on qualifications</div><div><div> 
</div></div></div><div>Description
Additional Position Details: FTE: 0.000001 | On Call | Variable Schedule Days
Starting Wage: $23.28-$32.02 per hour, depending on experience
Position Summary
The Case Management Specialist functions as a member of the Case Management team. They utilize communication, organizational, and problem-solving skills to carry out the post-hospital care plans and interventions, utilization review, and denials management activities as defined by the RN Discharge Coordinator and RN Utilization Reviewer. They assume a pivotal role with the patient care team to achieve optimal clinical and resource outcomes.
Position Qualifications
Experience<ul><li>
3 years of experience in administrative functions in care coordination and/or utilization management in healthcare settings is required.</li><li>
Experience with Microsoft Word and Excel is required</li><li>
Experience with EPIC is preferred</li><li>
Current understanding of CMS regulations related to hospital discharge requirements is preferred.</li></ul>
Education<ul><li>
High School Diploma, GED, or equivalent experience demonstrating the ability to effectively communicate as required for the position is required</li><li>
An Associate's degree in business, healthcare administration, or a related field is preferred</li></ul>
Total Rewards
We offer a comprehensive Total Rewards package designed to support your well-being and professional growth, including:<ul><li>
Competitive Pay: Hourly and salaried positions earn market-based compensation.</li><li>
Health &amp; Wellness: Medical, dental, and vision coverage for part-time and above employees and their eligible dependents beginning within 30 days of hire.</li><li>
Retirement Savings: Employer-sponsored retirement plan with company contribution and match.</li><li>
Paid Time Off: Generous ETO for part-time and above employees.</li><li>
Professional Development: Continue to enhance your education through our tuition reimbursement and tuition repayment program</li><li>
Additional Benefits: Life insurance, disability coverage, and employee assistance programs.</li></ul>
At Asante, we are guided by our values:
Excellence - Respect - Honesty - Service - Teamwork
Asante is proud to be an Equal Opportunity Employer. We are committed to creating a diverse and inclusive workplace and to employing and advancing qualified individuals of all backgrounds, including women, minorities, individuals with disabilities, and protected veterans.</div></div>

Case Management Specialist

TEEMA

<div><ul><li>13 week contract</li><li>
REQUIRED: 5+ years case management experience with 2+ years recent acute inpatient case management experience</li><li>
BSN or MSW, Current MI RN licensure or LMSW, Discharge planning experience.</li><li>
There will be limited training on site - candidates will need to be able to adapt quickly.</li><li>
Manager will be reaching out to candidates directly for interview</li><li>
MANAGER IS VERY STRICT ON THE RECENT INPATIENT CASE MANAGEMENT EXPERIENCE - TELEPHONIC, UTILIZATION REVIEW, PSYCHOLOGICAL EXPERIENCE DOES NOT APPLY TO THIS REQUIREMENT.</li></ul> 

#Workwolf</div>

Case Manager

Valley Medical Center

<div></div><div><div><div><ul><li><h6 class="jobSectionHeader">Job Title:</h6>
 Clinical Documentation Specialist
</li><li><h6 class="jobSectionHeader">Req:</h6>
 2026-0293
</li><li><h6 class="jobSectionHeader">Location:</h6>
 VMC Main Campus
</li><li><h6 class="jobSectionHeader">Department:</h6>
 Health Information Mgmt
</li><li><h6 class="jobSectionHeader">Shift:</h6>
 Days
</li><li><h6 class="jobSectionHeader">Type:</h6>
 Full Time
</li><li><h6 class="jobSectionHeader">FTE:</h6>
 1
</li><li><h6 class="jobSectionHeader">Hours:</h6>
</li><li><h6 class="jobSectionHeader">City State:</h6>
 Renton, WA
</li><li><h6 class="jobSectionHeader">Salary Range:</h6>
 Min $94,894 - Max $142,341/annual DOE</li></ul></div></div> 
 
 
 
Job Description:
VALLEY MEDICAL CENTER

JOB DESCRIPTION

The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands, and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization.

TITLE: Clinical Documentation Specialist RN

JOB OVERVIEW: The Clinical Documentation Specialist position facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the documentation improvement process is a key role.

DEPARTMENT: Health Information Management

HOURS OF WORK: Days Monday - Friday.

RESPONSIBLE TO: Manager, Clinical Documentation Improvement

PREREQUISITES:
<div>
<ul><li>Current unrestricted WA State Registered Nurse license, required.
</li></ul>
<ul><li>Bachelor's degree in Nursing, preferred.
</li></ul>
<ul><li>Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review
</li></ul>
<ul><li>Pass a pre-hire Clinical Exam with a minimum score of 70%
</li></ul>
<ul><li>Effective communication with Providers
</li></ul>
</div>QUALIFICATIONS:
<div>
<ul><li>Knowledge of hospital clinical practice standards for physicians and other health care providers.
</li></ul>
<ul><li>Knowledge of ancillary service departments, quality control and safety standards.
</li></ul>
<ul><li>Critical thinking, problem solving and deductive reasoning skills.
</li></ul>
<ul><li>Familiarity with health care audit and research design.
</li></ul>
<ul><li>Knowledge of Pathophysiology and Disease process.
</li></ul>
<ul><li>Functional knowledge of DRG coding systems.
</li></ul>
<ul><li>Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.
</li></ul>
<ul><li>Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.
</li></ul>
<ul><li>Meet productivity guidelines.
</li></ul>
<ul><li>Ability to learn/develop the skills necessary to perform and meet goal standards
</li></ul>
<ul><li>Organizational, analytical, writing, and interpersonal skills
</li></ul>
<ul><li>Dependable, self-directed, and pleasant
</li></ul>
<ul><li>Critical thinking, problem solving and deductive reasoning skills
</li></ul>
<ul><li>Knowledge of Pathophysiology and Disease Process
</li></ul>
<ul><li>Basic Computer skills - familiarity with Windows based software programs
</li></ul>
<ul><li>Knowledge of regulatory environment
</li></ul>
<ul><li>Understand and support documentation strategies (upon completion of training)
</li></ul>
<ul><li>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)
</li></ul>
</div>UNIQUE PHYSICAL/MENTAL DEMANDS, ENVIRONMENT AND WORKING CONDITIONS:

See Generic Job Description for Administrative Partner.

PERFORMANCE RESPONSIBILITIES:

A. Generic Job Functions: See Generic Job Description for Administrative Partner.

B. Essential Responsibilities and Competencies
<div>
<ul><li>Reviews EMR for completeness and accuracy for severity of illness and quality using the documentation strategies.
</li></ul>
<ul><li>Accurate and timely record review.
</li></ul>
<ul><li>Recognize opportunities for documentation improvement.
</li></ul>
<ul><li>Initiates severity worksheet for inpatients.
</li></ul>
<ul><li>Formulate clinically credible documentation clarifications.
</li></ul>
<ul><li>Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety.
</li></ul>
<ul><li>Effective and appropriate communication with physicians.
</li></ul>
<ul><li>Timely follow up on all cases and resolution of those with clinical documentation clarifications.
</li></ul>
<ul><li>Communicates with HIM staff and resolves discrepancies.
</li></ul>
<ul><li>Accurate input of data for reconciliation of case.
</li></ul>
<ul><li>Provide necessary information and education to physicians and staff to facilitate the appropriate documentation goals.
</li></ul>
<ul><li>Identify any barriers to completion of documentation goals with appropriate interventions.
</li></ul>
<ul><li>Review of regulations and coding guidelines through seminars, meetings, and materials.
</li></ul>
<ul><li>In cooperation with the director of PFS/HIM, present education sessions to physicians and other VMC providers regarding documentation regulations and chart audit findings.
</li></ul>
<ul><li>Maintains confidentiality of all accessible patient financial or medical records information.
</li></ul>
<ul><li>Demonstrates the awareness of the importance of cost containment for the department. Provide suggestions regarding process or quality improvement opportunities to department manager.
</li></ul>
<ul><li>Other duties as assigned to facilitate accurate, timely patient account management.
</li></ul>
</div>Date Created: 5/18, updated 7/22

Grade: NC11

FLSA: E

Cost Center: 8490 

Job Qualifications:
PREREQUISITES:
<div>
<ul><li>Current unrestricted WA State Registered Nurse license, required.
</li></ul>
<ul><li>Bachelor's degree in Nursing, preferred.
</li></ul>
<ul><li>Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review
</li></ul>
<ul><li>Pass a pre-hire Clinical Exam with a minimum score of 70%
</li></ul>
<ul><li>Effective communication with Providers
</li></ul>
</div>QUALIFICATIONS:
<div>
<ul><li>Knowledge of hospital clinical practice standards for physicians and other health care providers.
</li></ul>
<ul><li>Knowledge of ancillary service departments, quality control and safety standards.
</li></ul>
<ul><li>Critical thinking, problem solving and deductive reasoning skills.
</li></ul>
<ul><li>Familiarity with health care audit and research design.
</li></ul>
<ul><li>Knowledge of Pathophysiology and Disease process.
</li></ul>
<ul><li>Functional knowledge of DRG coding systems.
</li></ul>
<ul><li>Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.
</li></ul>
<ul><li>Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.
</li></ul>
<ul><li>Meet productivity guidelines.
</li></ul>
<ul><li>Ability to learn/develop the skills necessary to perform and meet goal standards
</li></ul>
<ul><li>Organizational, analytical, writing, and interpersonal skills
</li></ul>
<ul><li>Dependable, self-directed, and pleasant
</li></ul>
<ul><li>Critical thinking, problem solving and deductive reasoning skills
</li></ul>
<ul><li>Knowledge of Pathophysiology and Disease Process
</li></ul>
<ul><li>Basic Computer skills - familiarity with Windows based software programs
</li></ul>
<ul><li>Knowledge of regulatory environment
</li></ul>
<ul><li>Understand and support documentation strategies (upon completion of training)
</li></ul>
<ul><li>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)</li></ul></div></div>

Clinical Documentation Specialist

Search 10000+ Utilization management rn jobs near you this May. New roles added regularly across leading industries. Apply today.

10000 utilization management rn jobs Near Me

Utilization Management Registered Nurse

Utilization Management Registered Nurse

REMOTE Utilization Review Nurse - Managed Care

RN Integrated Care Manager

Case Management Specialist

Case Manager

Clinical Documentation Specialist