Utilization Review RN

JOB SUMMARY / PURPOSE

This will be a remote position.

Responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.

ESSENTIAL KEY JOB RESPONSIBILITIES:

1. Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews include admission, concurrent and post discharge for appropriate status determination.
2. Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility.
3. Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers.
4. Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes.
5. Collaborates with facility RN Care Coordinators to ensure progression of care.
6. Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.
7. Communicates the need for proper notifications and education in alignment with status changes.
8. Engages with Denials RN/Revenue cycle vendor to discuss opportunities for denials prevention.
9. Coordinates Peer to Peer between hospital provider and insurance provider, when appropriate.
10. Establishes and documents a working DRG on each assigned patient at the time of initial review as directed.
11. Demonstrates behavior that aligns with the Mission and Core Values of the Organization.
12. Responsible for completing required education within established timeframes.
13. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.
14. Participates regularly in performance improvement teams and programs as necessary.
15. Demonstrates behavior that aligns with the Mission and Core Values of the Organization.
16. Responsible for completing required education within established timeframes.
17. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.

Education and Experience:

Required:

• Graduate of an accredited school of nursing
• Minimum two (2) years of acute hospital clinical experience, or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.

Preferred:

• Bachelors Degree in Nursing (BSN) or related healthcare field.
• At least five (5) years of nursing experience.

Required Licensure and Certifications:

Required: ● Current licensure as a Registered Nurse in the state of Washington.

Preferred ● Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification preferred

BLS required within 3 months of hiring if located within hospital

Virginia Mason Franciscan Health has a rich history of providing exceptional healthcare, dating back to 1891. Building upon a legacy of compassionate care and innovation, our organization has evolved over the years through strategic partnerships and integrations to expand our reach and services across the Puget Sound area.

Today, as Virginia Mason Franciscan Health, we remain deeply committed to healing the whole person – body, mind, and spirit – in the communities we serve. This commitment is strengthened by the diverse expertise and shared values brought together through our growth.

Our dedicated providers offer a full spectrum of health care services, from routine wellness to complex disease management, all grounded in rigorous research and education. Our comprehensive network of 10 hospitals and nearly 300 care sites strategically located across the greater Puget Sound region reflects our ongoing commitment to accessibility and comprehensive care.

We are proud of our pioneering medical advances and numerous awards and accreditations that reflect our dedication to excellence. When you join Virginia Mason Franciscan Health, you become part of a team that delivers top-quality, professional healthcare in modern, well-equipped facilities, and contributes to a legacy of service built on collaboration and shared purpose.