BeavertonRecruiter Since 2001
the smart solution for Beaverton jobs

Registered Nurse (RN) Care Coordinator Quality Medical Management

Company: Providence Health & Services
Location: Beaverton
Posted on: February 13, 2021

Job Description:

Providence St. Joseph Health is calling a Registered Nurse (RN) Care Coordinator Quality Medical Management to our location in Beaverton, OR. We are seeking a Registered Nurse (RN) Care Coordinator Quality Medical Management to 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. In this position you will have the following responsibilities: 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 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. Functional area: Medical Policy and Criteria: * Develop medical policy and criteria to assure all policies and criteria are reviewed annually. Research and prepare documents needed for medical policy development, new technology assessment, new application of existing technology, drugs, and devices using resources such as the provider community, professional associations and organizations, technology assessment organizations, medline literature searches, and regulatory agencies. * Maintain files that document medical policy/procedure decisions, revisions, and annual reviews. * Collaborate with physicians and medical directors regarding pending policy decisions and communicate policy criteria to all departments, both internally and externally, on-line provider resources, handbooks and newsletters. * Facilitate and prepare documents for the Medical Policy Committee and Technology Assessment Committee. * Act as liaison to other departments providing information and decisions to improve operational efficiencies and communication with members, providers and staff. * Maintain files that document medical policy/procedure decisions, revisions, and annual reviews. * Collaborate with physicians and medical directors regarding pending policy decisions and communicate policy criteria to all departments, both internally and externally, on-line provider resources, handbooks and newsletters. * Facilitate and prepare documents for the Medical Policy Committee and Technology Assessment Committee. * Act as liaison to other departments providing information and decisions to improve operational efficiencies and communication with members, providers and staff. Functional Area: Clinical Appeals: * Maintain thorough knowledge of the appeal process following regulatory and accrediting requirements. * Maintain positive working relationships and serve as a clinical resource for the Appeals and Grievance department. * Maintain timeliness of the appeal review and all levels of the review process and required communication to the member, including an explanation of the decision rationale and a description of the review process. All areas: * Maintain program quality by completing routine audits, following department policies and procedures. Examples include: denial file audits, documentation standards, letters, turnaround times, interrater audits. Prepare audit reports for review, including corrective action plans. * Identify quality of care issues forwarding them to Quality Management for review. * Provide training and expertise on medically related issues across the organization. * Maintain a thorough knowledge of utilization management and cost containment strategies, member and providers contracts, all utilization management programs,workflow systems and personal computer software applications as appropriate. * Maintain a thorough knowledge of utilization management and cost containment strategies, member and providers contracts, all utilization management programs,workflow systems and personal computer software applications as appropriate. Required qualifications for this position include: * 5 years clinical nursing experience. * Experience working with physicians in collaboration and management of patient care. * Current license as a registered nurse in the state of Oregon. Preferred qualifications for this position include: * Bachelor's Degree in Nursing or health care. * Utilization review, discharge planning and/or managed care experience. About Providence in Oregon. As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities. The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple, "Providence will provide the best care and service to every person, every time." Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.

Keywords: Providence Health & Services, Beaverton , Registered Nurse (RN) Care Coordinator Quality Medical Management, Executive , Beaverton, Oregon

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category
within


Other Executive Jobs


Critical Infrastructure Manager II
Description: This position is responsible for the management of data center responsibility within an assigned area, and the oversight of all critical infrastructure engineers CIE and critical infrastructure mangers (more...)
Company: Flexential
Location: Portland
Posted on: 02/25/2021

BC/BE Pathology Medical Director - 4 hours per Week - Portland, Oregon
Description: Pathology opening in Portland, Oregon. This and other physician jobs brought to you by DocCafe.com - Immediate opening for a part time, Contract Physician - Alternate Center Medical Director for plasma (more...)
Company: Integrity Healthcare
Location: Portland
Posted on: 02/25/2021

6280 - Chief Technology Officer (CTO
Description: This position holds an office out of the Lloyd Administrative offices in NE Portland, near the Lloyd center. The the position will be given the opportunity to work remotely as able to, until state restrictions (more...)
Company: Cascadia Behavioral Healthcare, Inc
Location: Portland
Posted on: 02/25/2021


Associate Director of Special Projects and Initiatives
Description: The Annual Security Report and Annual Fire Safety Report that complies with the Jeanne Clery Act. Associate Director of Special Projects and Initiatives Below you will find the details for the position (more...)
Company: University of New England
Location: Portland
Posted on: 02/25/2021

Champions Site Director - Margaret Scott Elementary
Description: Covid-19 update:-- Ensuring the health and safety of our staff and the families we serve is our first priority. For more information, read our statement here: Champions Site Director - Margaret Scott (more...)
Company: KinderCare Education
Location: Portland
Posted on: 02/25/2021

Director of Operations
Description: Careers - Avamere Family of Companies - Director of Operations in Clackamas, Oregon - Careers at Exiges Portable Imaging Skip Branding Quick Links ul li Health Care Choices li Senior Living Choices (more...)
Company: e Avamere Family of Companies
Location: Clackamas
Posted on: 02/25/2021

Case Management Travel RN - Job Id: JO02989377
Description: Next Travel Nursing is seeking a qualified
Company: Next Travel Nursing
Location: Portland
Posted on: 02/25/2021

Client Service Senior Project Manager
Description: MPX is seeking an experienced professional in the Print and Digital Fulfillment, Digital Mailroom, Insert and Direct Mailing space to join our team as a Client Service Senior Project Manager. MPX has (more...)
Company: KMA Human Resources Consulting LLC
Location: Portland
Posted on: 02/25/2021

Hospitalist Medical Director Needed in Portland, Oregon
Description: Hospitalist Medical Director Needed in Portland, Oregon Full Time BE or BC Adventist Health Portland seeks an experienced Board-Certified internal medicine physician to join the OHSU-Adventist Hospitalist (more...)
Company: Health eCareers
Location: Portland
Posted on: 02/25/2021

Director/Vice President of Sales
Description: Your Home Building Career Starts Here - Richmond American Homes ul li Find a home li Design a home li Research us li See what's new li Email alerts ul li li Sign in/Join li Contact (more...)
Company: MDC Holdings, Inc. / Richmond American Homes
Location: Portland
Posted on: 02/25/2021

Log In or Create An Account

Get the latest Oregon jobs by following @recnetOR on Twitter!

Beaverton RSS job feeds