RN - Utilization Review
About The Position
The Utilization Review (UR) Nurse combines a strong clinical background with knowledge and skills in Utilization Management (UM), medical necessity, and patient status determination. The role supports the UM program by developing and maintaining effective, efficient processes for determining appropriate admission status in accordance with regulatory and reimbursement requirements of commercial and government payers. The nurse uses appropriate criteria and interprets clinical status and treatment plans in light of current federal regulations and guidelines to expedite billing and payment and help prevent governmental sanctions. The UR Nurse performs comprehensive admission, concurrent, and retrospective utilization reviews and related functions to ensure appropriate data is tracked, evaluated, and reported. The role actively participates in process improvement initiatives and works with multiple departments and multidisciplinary staff. It requires current and accurate knowledge of commercial and government payers, as well as accreditation regulations, guidelines, and criteria related to utilization management. The position is with Providence Centralia Hospital, where caregivers support patient-focused, whole-person care built on understanding, commitment, and mutual respect.
Requirements
- Associate's Degree in Nursing.
- Current Washington Registered Nurse License upon hire.
- 3 years of nursing experience.
Nice To Haves
- Bachelor's Degree in Nursing.
- 3 years of experience in Utilization Review, Care Management, Quality Management, and/or Discharge Planning.
Responsibilities
- Develop and maintain effective, efficient processes for determining appropriate admission status in accordance with payer regulatory and reimbursement requirements.
- Apply appropriate criteria and interpret clinical status and treatment plans in relation to federal regulations and guidelines.
- Support timely billing and payment and help prevent governmental sanctions.
- Perform comprehensive admission, concurrent, and retrospective utilization reviews and related functions.
- Ensure appropriate utilization review data is tracked, evaluated, and reported.
- Participate in process improvement initiatives and collaborate with multiple departments and multidisciplinary staff.
- Maintain current and accurate knowledge of commercial and government payers and accreditation regulations, guidelines, and criteria related to utilization management.
Benefits
- Benefits designed to support employees and their families in staying well, growing professionally, and achieving financial security.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Education Level
Associate degree
