Utilization Review RN

Providence • Portland, OR

1d • Remote

About The Position

The RN Care Coord-Qual Med Mgmt will 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. Providence Health Plan caregivers are not simply valued – they’re invaluable. Join our team at Providence Health Plan Partners and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them. This position works 100% remote and is open to candidates residing in: Oregon Washington

Requirements

• 5 years Clinical nursing experience.
• Upon hire: Oregon Registered Nurse License and Washington State Registered Nurse License
• Experience working with physicians in collaboration and management of patient care.

Nice To Haves

• Bachelor's Degree Nursing or health care.
• Utilization review, discharge planning and/or managed care experience.
• Psychiatric Mental Health Nurse Certification PMH-BC

Responsibilities

• Provide administration of medical management programs including prior authorization, concurrent hospital and skilled nursing review, appeals and grievance, delegation, medical policy development and medical claims audits.
• Manage medical expense, determine medically appropriate services and define clinical criteria for decision making.
• Conduct retrospective review of claims and other data.
• Perform care coordination and discharge planning.

Benefits

• Best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally, and achieving financial security.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level