Nurse Utilization-RN NE

Location: Wenatchee, WA
Facility: Confluence Health
Schedule: Full Time
Shift: Day Shift

Job Description
Position Summary:
  • Performs utilization review in accordance with all state mandated regulations. Maintains compliance with regulation changes affecting utilization management. Reviews patients’ records and evaluates patient progress. Performs continuing review on medical records and identification and need of on-going hospitalization. Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct review Reviews and validates physician’s orders, reports progress and unusual occurrences on patients. Ensures appropriate and cost-effective healthcare services to patients. Documents review information in computer.
Essential Functions:
  • Essential Functions:
    • Prepares and organizes initial and continued stay utilization reviews.
      • Complete admission review per MCG guidelines.
      • Document variances as appropriate.
      • Coordinates provider certification of Medicare inpatient hospital stays as required in the Medicare Benefit Manual, Final Rule etc.
      • Utilizes clinical information located in the patient record to support patient status decisions and recommendations. Documents this information in MCG.
    • Collaborates with other departments regarding review results.
      • Notifies patient accounts of Condition Code 44, A/B rebills, and payer denials.
      • Communicates changes of observation to inpatient status to care management staff.
      • Communicates to care management staff when payers request additional information related to discharge planning and other needs.
    • Complies with Medicare and other regulations for second level review by the UR Committee, notification of patient, physician, and hospital of particular status changes.
      • Follows the Condition Code 44 or A/B Rebill flow maps as indicated.
      • Ensures written notification of the patient, physician, and hospital when the final outcome of a second level review is Condition Code 44 or A/B Rebill.
      • Notifies patient accounts to hold submission of a bill when a case has been sent for second level review and the patient has been discharged.
      • Notifies patient accounts to submit the bill when the results of the second level review is known, along with the results.
      • Participates in tracking and monitoring second level reviews as directed.
    • Adheres to Workflows and Process Maps specific to UM functions.
      • Follows process flow maps and established workflows. Participates in standard work.
      • Assist in identifying processes and procedure improvements to positively affect work flows.
    • Issues Notices of Non-coverage according to policy and procedure.
    • Complies with the various private contracts regarding review, pre-authorization, phone calls, deliver non-coverage letters as required and/or appeal denials.
      • Provides Clinical information to payers as requested and per contract.
      • Facilitates concurrent Peer to Peer discussions between providers when a payer denies all or part of a hospital stay when the denial occurs prior to discharge.
      • Communicates the results of Peer to Peer discussions, if known, with business office and patient accounts.
      • Tracks all discussions with payers in the appropriate billing system, according to facility.
    • Assist with the process following an appeal of discharge, as outlined in the Important Message from Medicare.
      • Provide requested clinical information to the QIO following a patient’s appeal of the discharge decision.
      • Deliver a HINN-12 notification following a decision from the QIO to uphold a decision to discharge, according to procedure.
      • Communicate changes in Medicare reimbursement policy to providers and Confluence Health employees as directed.
  • Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times.
  • Required:
    • Consideration will be given to an applicant enrolled in a BSN program with commitment to finish the program in an agreed-upon time.
    • Three (3) years experience in an acute care setting as a Health Care Professional with demonstrated expertise in specific clinical area.
    • Demonstrated skills in the areas of negotiation, communication (verbal and written), conflict, interdisciplinary collaboration, management, creative problem solving, and critical thinking. Knowledge of healthcare financing, community and organizational resources, patient care processes, and data analysis.
    • Excellent verbal and written communication skills.
    • Demonstrates flexibility via an ability to adapt to changing priorities and regulations.
    • Current licensure in the state of Washington (RCW 18.88).
    • Must be currently certified in BLS, and recertified annually.
    • Knowledge of utilization management
    • Knowledge of Regulatory Requirements.
    • Must possess basic computer skills related to Windows navigation, mouse usage, keyboarding, email communication and password management.
  • Desired:
    • Bachelor of Science in Nursing.
    • Nursing degree ADN or Diploma with Bachelor in health care or related field.
    • Masters in a related or complementary field with underlying Nursing Degree.
    • Accreditation in ACMA
Additional Information

About Confluence Health: Confluence Health is an integrated, rural healthcare delivery system with two hospitals, multi-specialty care in 30+ service lines and primary care in 11 communities across north central Washington State. Our 270 physicians and 130 advanced practice clinicians serve an area of approximately 12,000 square miles and cover nearly every corner of this region through specialty outreach. Our Mission: We are dedicated to improving our patients' health by providing safe, high-quality care in a compassionate and cost effective manner. Our Setting and Lifestyle: We are located in the heart of Washington State and just 2.5 hours east of Seattle. Our region offers a diverse array of recreational opportunities in breathtaking landscapes, from alpine country to the high desert, orchards to vineyards, cross country skiing to fly fishing and everything in between. Cycling, mountain biking, rafting, hiking; it is all right here. The region also offers a family friendly environment with excellent schools and cultural and art activities for the entire family.