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Utilization Review Nurse Specialist

1 month ago

Bellevue, Washington, United States Overlake Medical Center Full time
Job Summary

Welcome to Overlake Medical Center, where we're dedicated to delivering exceptional patient care. As a Utilization Review Nurse, you'll play a vital role in ensuring our patients receive the right care at the right time.

Key Responsibilities
  • Collaborate with the care team to assure high-quality, safe, and cost-effective patient care.
  • Drive adherence to regulatory and payer guidelines, working in partnership with Social Workers to ensure appropriate continuity of care.
  • Perform preadmission, admission, and continued stay reviews to ensure appropriate patient class and medical necessity of all observation and acute care hospitalizations.
  • Utilize clinical knowledge and expertise to assure patients receive the right care at the right time.
  • Intervene with physicians, nursing, social work, and ancillary departments to resolve delays in service, inappropriate patient class, or quality of care issues.
  • Follow up with attending physicians when patients do not meet MCG criteria and/or clinical criteria that supports acute care hospitalization/observation.
  • Act as a consultant to educate patients, families, and staff regarding Medicare/Medicaid guidelines, compliance with external review organizations, and potential alternatives to acute care hospitalization.
  • Maintain assigned work queues, such as discharges, short stays, prior authorization, etc.
  • Review all observation cases to ensure appropriate setting, admissions, or timely discharge.
Qualifications
  • Associate's degree in nursing required; Bachelors or Masters in nursing preferred.
  • Current Washington State license as a Registered Nurse required; Certified Case Manager (CCM) or Accredited Case Manager (ACM) certification preferred.
  • Three years acute care experience required; prior utilization management, case management, compliance, or payer experience required.
  • Ability to effectively present information and respond to questions from groups of managers, patients, physicians, and payors.
  • Knowledge of word processing, spreadsheet, database, and presentation software.
Why Choose Overlake Medical Center?

We offer a values-based work environment, local leaders who care about you, and a commitment to diversity, equity, and inclusion. Enjoy benefits like medical insurance premiums as low as $0 per month, tuition reimbursement up to $10,000 per year, and a generous retirement plan matching up to 7% with company match 100% vested.