Responsible for fulfilling Hospital Utilization Management policies and procedures by performing review of scheduled or unscheduled patient admissions, from admit date through discharge, for appropriate level of care classification. Applies knowledge of nationally recognized admission criteria, (InterQual and Milliman Care Guidelines) SCH hospital guidelines of care, standard clinical pathways and evidence based practices to analyze the patient medical record and make level of care classification decisions. Communicates review decisions with patient’s health plan and obtains health plan authorization for reimbursement of admission Works in partnership with the health care team to resolve classification or authorization issues. Identifies and escalates trends in payer denials and under or over utilization, or internal failure to follow standard clinical or evidence based care. Provides clinical expertise, coaching and support to non clinical staff performing authorization work in the Utilization Review Specialist and Insurance Processing Department teams.
- Registered Nurse.
- Minimum three years of inpatient acute care nursing experience, preferably in pediatrics.
- Minimum three years of relevant authorization, utilization review, case management, or denial management experience, either at a health plan or within a health care delivery system.
- Current Washington State RN licensure.
- Current Basic Life Support (BLS) for Healthcare Providers. Current PEARS or PALS certification will be accepted in lieu of BLS.
- Bachelor of Science, Nursing.
- Five years experience with insurance authorization and/or utilization review processes.
- Five years inpatient pediatric nursing experience.
- Demonstrated competency with the use of Milliman and Interqual criteria sets.