• Utilization Review Nurse

    Job ID 2018-28989
    Area of Interest
    Utilization Review
    Location Name
    Roosevelt Commons
    FTE/Hours per pay period
    1.0 FTE (80 hours per bi-weekly pay periods)
    Work Status
    Utilization Review
    Day Shift
  • Overview

    Telecommuting position with mandatory monthly onsite meetings. 

    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.


    Employer Offerings: To attract and retain the best workforce, we provide competitive salaries, great benefits and excellent professional development. Those are some of the reasons Those are some of the reasons Becker’s Hospital Review listed us as one of 150 Great Places to Work in Healthcare. Offerings include:

    • Transportation Subsidies
    • Vera Whole Health: Access to free health and wellness services at our near-site employee clinics.
    • Childcare Subsidy Program-provides eligible employees with financial assistance to supplement basic child care costs.
    • Care-Services: Back-up care for children and adult/senior care planning
    • Inclusion Networks: The Inclusion Network is Seattle Children's organizational resource group program. It is an interconnected community of Children's employees who are committed to the Inclusion Network mission and vision. Individual Networks include: Q Pod (LGBTQ) Network, Green Team (Sustainability) Network, Hola (Hispanic/Latino) Network, Indigenous Peoples Network, Parenting Network, Black and African Heritage Network

    Our community welcomes diverse experiences, backgrounds and thoughts because this is what drives our spirit of inquiry and allows us to better connect with our increasingly diverse patients and families. Each of us is respectfully encouraged to be ourselves within this community, which cultivates and promotes diversity and inclusion at all levels.



    Required Education/Experience:
    - 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.

    Required Credentials:
    - 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.
    - 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.
    - 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.


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