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Hiring Drivers Now · Centralia, WA

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Utilization Review Nurse This position has a remote option for those living close and will be able to come into the hospital as needed. The Utilization Review Nurse is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services "CMS" Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and guidelines related to UM. This nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Review Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS. Responsibilities: • Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders. • The prior authorization role completes an assessment of a proposed service to determine if the beneficiary has eligible coverage for the service and if it is medically necessary. • Promote quality, cost-effective outcomes through prior authorization and concurrent review of requested services for medical necessity based upon evidence-based clinical guidelines. • Identify and present cases of possible quality of care deviations, questionable admissions, and prolonged lengths of stay to the Medical Director for further determination. • Appropriately refer beneficiaries who have complex or chronic conditions, a need for transition of care, disease management support, or other identifiable needs for coordination of the beneficiary's member's health care for behavioral health care management. • Follow CHRISTUS Health Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent, or detect unauthorized disclosure of Protected Health Information (PHI). • Protect the confidentiality of data and intellectual property; assures compliance with national health information guidelines. • Analyze clinical information submitted by medical providers to evaluate the medical necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities. • Perform provider outreach to address post-hospital discharge services, redirection to in-network providers for appropriate steerage, durable equipment usage, and utilization of other medical services and/or procedures and other necessary telephonic follow-up. • Utilize the nursing process and critical thinking skills to provide oversight of services and evaluation of service options. • Ability to work in a variety of settings with culturally diverse communities with the ability to be culturally sensitive and appropriate. • Must have excellent communication skills (written and verbal), clinical judgment, initiative, critical thinking, and problem-solving abilities. • Must be able to take after hour calls to meet business requirements as needed. Job Requirements: Education/Skills • Graduate of an accredited school of vocational nursing or equivalent required • Associate's (ADN) or Bachelor's (BSN) in Nursing preferred Experience • 3 – 5 years of nursing experience preferred • Experience in Microsoft software (e.g., Outlook, Teams, Word, and Excel) required • General computer knowledge and capability to use computers required Licenses, Registrations, or Certifications • LVN license in the state of employment or compact required • RN license in state of employment or compact preferred Work Schedule: 5 Days - 8 Hours Work Type: Full Time

Utilization Review Nurse

Cobalt Benefits Group · Centralia, WA

Utilization Review Nurse (Ur Nurse) Join our team at Cobalt Benefits Group and start an exciting new career in employee benefits solutions. As a Utilization Review Nurse (UR Nurse), you'll play an important role in helping us offer customized, self-funded insurance options to our clientsand members. The UR Nurse is responsible for reviewing clinical information to determine the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and levels of care in accordance with established criteria, payer guidelines, and organizational policies. This role involves evaluating healthcare services and facilities under the provisions of applicable health benefit plans to ensure quality and cost-effective patient care. The UR Nurse collaborates closely with intake staff, physicians, specialists, case managers, and other members of the care team to facilitate timely and effective care authorizations, transitions, and utilization determinations. Strong communication, clinical judgment, and attention to detail are essential to ensure services meet both clinical standards and benefit requirements. Responsibilities • Perform utilization and concurrent reviews of inpatient cases using Milliman, Aetna, and BCBS criteria. • Conduct medical necessity reviews for services requiring prior authorization, applying utilization-specific criteria. • Request and evaluate clinical information needed to review requested services. • Discuss cases and determinations with healthcare professionals and physician reviewers. • Identify cases requiring intervention and collaborate with Case Managers as needed. • Maintain appropriate and accurate documentation, ensuring compliance with audit standards. • Participate in team meetings, educational sessions, and related activities. • Review medical claims and pre-determinations for medical necessity and appropriateness. • Identify opportunities for process improvement and enhance communication among departments. • Consult with Physician Reviewers for complex or challenging cases. Requirements • Current, unrestricted RN license (State license required). • Minimum 3 years of clinical nursing experience. • Minimum 1 year of Utilization Management (UM) or Utilization Review (UR) experience. • Strong analytical, critical thinking, and problem-solving skills. • Proficiency in Microsoft Office Suite (Excel, Word, Outlook) and familiarity with utilization management systems. • Excellent verbal and written communication skills, with the ability to interact effectively with internal and external stakeholders. • Strong organizational and time management skills, with the ability to handle multiple priorities independently. Preferred Qualifications • Experience with Milliman or Aetna criteria. • Background in healthcare administration, medical necessity determination, or benefits management. • Experience in data interpretation and medical trend analysis. Work Environment & Physical Demands • Prolonged periods of sitting may be required. • Regular use of a computer, keyboard, and mouse is necessary; reasonable accommodations will be provided upon request. • Employees should ensure an ergonomically appropriate desk and chair setup. • Comfort with being on camera for virtual meetings (e.g., Microsoft Teams) Benefits After successfully completing a waiting period, eligible full-time employees have access to our comprehensive benefits package, including: • Fantastic medical, dental, and vision insurance* • Twice annual employer HSA contributions, covering 50% of the HDHP plan's annual deductible! • Company-provided Basic Life and AD&D • Company-paid Short-Term and Long-Term Disability** • Flexible Spending Accounts* • 401(k) Retirement Plan with up to a 6% employer match** (100% fully vested after 3 years) • 10+ paid holidays • Half-day Summer Fridays • Generous paid vacation and sick time • Annual paid Volunteer Day • Annual Tuition reimbursement • Annual Health and Wellness reimbursement • Lots of fun company events Benefit Waiting Period Notes: *60-day waiting period, **90-day waiting period Who We Are As a trusted Third-Party Administrator (TPA) specializing in self-funded benefit plans, Cobalt Benefits Group (CBG) is committed to helping employers find high-quality coverage at a cost they can afford. We administer self-funded insurance benefits through our four companies: EBPA, Blue Benefit Administrators of Massachusetts, CBA Blue, and Great Bay Administrators. With over 30 years of experience and a dedicated team of nearly 300 employees, we work collaboratively to build customized self-funded health plans, manage claim payments and disputes, and administer other specialized programs such as FSAs, HSAs, COBRA, and retiree billing. Cobalt Benefits Group is one of the fastest growing TPA's in the country and the fastest growing in New England. Join us as we match employers across our region with the right solutions for their employee benefit needs.

$17.25–$18.50/hr

Customer Care Representative I

Quest Diagnostic · Centralia, WA

Customer Care Representative I - Lenexa, KS Demonstrates skill and passion to deliver an exceptional and consistent customer experience of a routine complexity, while utilizing multiple customer communication channels, which may include voice, mail, email, chat, AI related inquiries, etc. Start date: August 17th Training: Must be able to attend training onsite for 5 weeks in Renner Blvd. Lenexa, KS. Schedule is Monday- Friday, 7:00AM - 4:00PM Central. Work Schedule: Remote, Monday - Friday, 9:30AM - 6:00PM Central. Pay Range: $17.25 - $18.50 per hour. Salary offers are based on a wide range of factors including relevant skills, training, experience, education, and, where applicable, certifications obtained. Market and organizational factors are also considered. Successful candidates may be eligible to receive annual performance bonus compensation. Benefits information: We are proud to offer best-in-class benefits and programs to support employees and their families in living healthy, happy lives. Our pay and benefit plans have been designed to promote employee health in all respects – physical, financial, and developmental. Depending on whether it is a part-time or full-time position, some of the benefits offered may include: • Day 1 Medical, supplemental health, dental & vision for FT employees who work 30+ hours • Best-in-class well-being programs • Annual, no-cost health assessment program Blueprint for Wellness® • HealthyMINDS mental health program • Vacation and Health/Flex Time • 6 Holidays plus 1 "MyDay" off • FinFit financial coaching and services • 401(k) pre-tax and/or Roth IRA with company match up to 5% after 12 months of service • Employee stock purchase plan • Life and disability insurance, plus buy-up option • Flexible Spending Accounts • Annual incentive plans • Matching gifts program • Education assistance through MyQuest for Education • Career advancement opportunities • and so much more! Responsibilities Supports assigned client group(s) performing routine complexity health related customer excellence activities. • Handles routine Outbound and Inbound Full Service calls in a timely manner following set scripts and procedures, as applicable. • Maintains complete customer/patient confidentiality for all health, personal and other customer information. • Provides professional, respectful, customer excellence. Demonstrates caring and empathy when delivering sensitive health information. • Effectively respond to all customer inquiries received by various digital methods including telephone, fax, email chat regarding reporting of patient results, inquiries of tests and services, concerns of service failures and other duties needed to provide superior service. • Supports all client group(s) based on business needs. Qualifications Required Work Experience: • 1-year related customer service excellence experience. Preferred Work Experience: • Health care and laboratory related experience. • Experience delivering customer service excellence and achieving productivity/accuracy/quality standards. Physical and Mental Requirements: • Consistent exceptional customer service, accuracy and quality focus required. Knowledge: Align to Quest Culture & How We Work: • CUSTOMER FIRST - We serve the needs of our patients and customers first and foremost. • CARE - We show each person they matter. • COLLABORATION - We commit teamwork - inside and outside of Quest. • CONTINUOUS IMPROVEMENT - We challenge ourselves to make each day better than the last. • CURIOUSITY - We ask vital questions in search of richer answers. • FOUNDATIONAL REQUIREMENTS: Good performance & productivity, good attendance, good conduct, good teamwork. Skills: • Prefer good digital skills computer (Outlook & Excel), phone systems, chat, automation, and AI. • Continuous Improvement: Embrace and thrive in an environment of continuous improvement, innovation, and leveraging digital About the Team Quest Diagnostics honors our service members and encourages veterans to apply. While we appreciate and value our staffing partners, we do not accept unsolicited resumes from agencies. Quest will not be responsible for paying agency fees for any individual as to whom an agency has sent an unsolicited resume. Equal Opportunity Employer: Race/Color/Sex/Sexual Orientation/Gender Identity/Religion/National Origin/Disability/Vets or any other legally protected status.