Registered Nurse-Care Coordinator/Quality Medical Management
About the Job
Providence is calling a full-time Registered Nurse Care Coordinator - Quality Medical Management for a day shift position at Providence Murray Business Center in Beaverton, OR.
In this position, you will: Provide administration of medical management programs that include: prior authorization, concurrent hospital and skilled nursing review, appeals and grievance, delegation, medical policy development and medical claims audits. These programs are developed to manage medical expense, determine medically appropriate services and define clinical criteria for decision making. This includes retrospective review of claims and other data, as well as care coordination and discharge planning.
Specific Functional areas Functional area: Medical Review (Concurrent Review and Prior Authorization)
Perform onsite and telephone concurrent review of hospitalized members, skilled nursing, acute rehabilitation or other services, following Quality Medical Management(QMM)policies and procedures and documentation standards.
Initiate and/or participate in discharge planning for hospitalized members, including case conferences and care coordination upon discharge.
Develop and maintain a thorough knowledge of Interqual criteria and concurrent review policies, procedures and approved resources.
Review requests for prior authorization following all lines of business criteria, health plan medical policy criteria and department policies and procedures, including required timelines.
Functional area: Medical Claims Audit
Review claims pended for medical review or for specified claims audits, following department policies and procedures. Claims reviews are done for medical necessity, billing accuracy and appropriate coding.
Maintain accurate and timely documentation, as outlined in the department policies and procedures. This includes approval and all denial letters and additional communications as indicated by lines of business.
Effectively communicate the findings from review activities to providers, members and internal staff as outlined in the department policies and procedures.
Track and report determinations, savings, turnaround time, and medical information related to the review criteria.
Required qualifications for this position include:
Must have a current license as a registered nurse in the state of Oregon
Valid Drivers license.
Minimum five (5) years of clinical nursing experience with preference given to experience in utilization review, discharge planning and/or managed care.
Demonstrated creativity and flexibility in problem solving and development of alternative approaches to the traditional delivery of health care.
Experience working with physicians in collaboration and management of patient care and/or utilization review.
Preferred qualifications for this position include: