Utilization Review Nurse

4 days ago


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

We are seeking a highly skilled Utilization Review Nurse to join our team at Overlake Medical Center. As a Utilization Review Nurse, you will play a critical role in ensuring that patients receive the right care at the right time, while also driving adherence to regulatory and payer guidelines.

Key Responsibilities
  • Conduct preadmission, admission, and continued stay reviews to ensure appropriate patient classification and medical necessity of all observation and acute care hospitalizations.
  • Utilize clinical knowledge and expertise to ensure patients receive the right care at the right time.
  • Collaborate with physicians, nursing, social work, and ancillary departments to resolve delays in service, inappropriate patient classification, 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.
Requirements
  • Associate's degree in nursing required; Bachelor's or Master's 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 Join Our Team?

We are proud to offer benefits that support you in every stage of your career and life. Our inspirational culture is built on local, visible leaders who care about you, a values-based work environment, and an active Diversity, Equity & Inclusion Council.

We offer:

  • Medical insurance premiums as low as $0 per month.
  • Many Overlake services covered at 100%.
  • Tuition reimbursement up to $10,000 per year.
  • Generous retirement plan matching up to 7% with company match 100% vested.
  • An expanded Employee Assistance Program.
  • A caregiver support program to help with everything from childcare to eldercare.
  • Free parking and Orca transit passes.


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