Registered Nurse (RN) Care Coordinator Quality Medical Management
Company: Providence Health & Services
Location: Beaverton
Posted on: February 13, 2021
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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
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