Utilization Review RN

In 2020, united in a fierce commitment to deliver the highest quality care and exceptional patient experience, Virginia Mason and CHI Franciscan Health came together as natural partners to build a new health system centered around the patient: Virginia Mason Franciscan Health. Our combined system builds upon the scale and expertise of our nearly 300 sites of care, including 11 hospitals and nearly 5,000 physicians and providers. Together, we are empowered to make an even greater impact on the health and well-being of our communities. 

CHI Franciscan and Virginia Mason are now united to build the future of patient-centered care across the Pacific Northwest. That means a seamlessly connected system offering quality care close to home. From basic health needs to the most complex, highly specialized care, our patients can count on us to meet their needs with convenient access to the region’s most prestigious experts and innovative treatments and technologies.  

While you’re busy impacting the healthcare industry, we’ll take care of you with benefits that may include health/dental/vision, FSA, matching retirement plans, paid vacation, adoption assistance, annual bonus eligibility, and more!

Job Summary:

This role is responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.

Essential Key Job Responsibilities

1. Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking.  Reviews include admission, concurrent and post discharge for appropriate status determination.
2. Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility.
3. Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers. 
4. Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes.
5. Collaborates with facility RN Care Coordinators to ensure progression of care.
6. Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.
7. Communicates the need for proper notifications and education in alignment with status changes.
8. Engages with Denials RN/Revenue cycle vendor to discuss opportunities for denials prevention.
9. Coordinates Peer to Peer between hospital provider and insurance provider, when appropriate.
10. Establishes and documents a working DRG on each assigned patient at the time of initial review as directed.
11. Demonstrates behavior that aligns with the Mission and Core Values of the Organization.
12. Responsible for completing required education within established timeframes.
13. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.
14. Participates regularly in performance improvement teams and programs as necessary.
15. Demonstrates behavior that aligns with the Mission and Core Values of the Organization. 
16. Responsible for completing required education within established timeframes.
17. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.

Required Education and Experience:

Graduate of an accredited school of nursing

Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.

Preferred:

• Bachelor's Degree in Nursing (BSN) or related healthcare field.
• At least five (5) years of nursing experience.

Required Licensure and Certifications:

Current licensure as a Registered Nurse in the state of Washington.

Preferred: 

Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification preferred.