RN - Utilization Review

About the role

The Utilization Review (UR) Nurse combines a strong clinical background with expertise in Utilization Management (UM), medical necessity, and patient status determination. This role supports the UM program by developing and maintaining efficient processes to determine appropriate admission status based on regulatory and reimbursement requirements for commercial and government payers. The UR Nurse applies appropriate criteria, interprets clinical status and treatment plans in alignment with federal regulations, and ensures expedited billing, payment, and compliance to prevent governmental sanctions.

The UR Nurse performs comprehensive admission, concurrent, and retrospective reviews, tracks and evaluates relevant data, and reports findings. This individual actively participates in process improvement initiatives, collaborating with multiple departments and multidisciplinary staff. The role requires up-to-date knowledge of commercial and government payers, as well as accreditation regulations and guidelines related to UM.

Responsibilities

• Develop and maintain effective, efficient processes for determining appropriate admission status based on regulatory and reimbursement requirements.
• Utilize appropriate criteria to interpret clinical status and medical treatment plans in alignment with federal regulations and guidelines.
• Perform comprehensive admission, concurrent, and retrospective utilization reviews.
• Track, evaluate, and report data related to UR functions.
• Participate in process improvement initiatives across multiple departments and with multidisciplinary staff.
• Ensure compliance with payer and accreditation regulations to prevent sanctions and expedite billing and payment.

Requirements

• Associate's Degree in Nursing (required).
• Washington Registered Nurse License (required upon hire).
• 3 years of experience in Nursing (required).
• Bachelor's Degree in Nursing (preferred).
• 3 years of experience in Utilization Review, Care Management, Quality Management, and/or Discharge Planning (preferred).

Benefits

Providence offers a comprehensive benefits package, including:

• Retirement 401(k) Savings Plan with employer matching.
• Health care benefits (medical, dental, vision).
• Life insurance and disability insurance.
• Paid parental leave, vacation, holidays, and time off for health issues.
• Voluntary benefits and well-being resources.

Pay

The pay range for this position is $50.14 - $77.83 per hour. The successful candidate's placement on the wage range will be determined based on relevant job experience and other applicable factors. Additional compensation may be available, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

Schedule

Per-Diem, Day shift.