Utilization Review Nurse Health Plans - Case Management
CHRISTUS Health · Centralia, WA
Job description
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
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Licensed Psychiatric Nurse Practitioner
Headway · Centralia, WA
" Licensed Psychiatric Nurse Practitioner Wage: Up to $206.36/hour Did you know that you can build a flexible private practice on your terms as a psychiatric nurse practitioner? Whether you want to see patients alongside a full-time job or grow a full-time practice, Headway makes it easy to accept insurance, boost your earnings, and focus on care - without the administrative burden. It's all on one free-to-use platform, no commitment required. About the role This position is for licensed psychiatric nurse practitioners looking to start or grow their private practice. Headway provides the tools, resources, and support to help you navigate insurance, streamline operations, and let you focus on what matters most - your patients. About you • You're a fully licensed psychiatric nurse practitioner with your DEA or CDS number, ANCC or AANP board certification, a valid NPI number and malpractice insurance. • You're looking to start or expand your private practice while maintaining control over your schedule, client load, and work environment. Why partner with Headway? As an independent provider with Headway, you'll gain access to: • Hassle-free insurance credentialing: Get credentialed for free in multiple states within as little as 30 days. • Increased earnings: Secure competitive rates with top insurance plans through our nationwide network. • Predictable bi-weekly payments: Receive reliable payouts directly from Headway. • Built-in EHR tools: Access real-time scheduling, secure client messaging, documentation templates, assessments, and more. • Compliance & audit support: Stay up-to-date with insurance requirements and industry regulations. • Free continuing education: Earn CEUs and expand your expertise through Headway Academy. How Headway supports your patients • Increased access: Headway makes it easier for your clients to get the care they need at a price they can afford through insurance. • Instant verification: Clients can easily check their insurance status and get the care they need without disruption. Important Notes • This is a 1099 independent contractor role. You'll have full autonomy over your practice, including setting your hours and managing your caseload. • At this time, Headway can't support mental health professionals that aren't fully licensed. If your application was rejected for incomplete licensure, you're welcome to reapply once you have a valid license. About Headway We make it easy for mental health providers to take insurance by credentialing you with the nation's largest networks, handling billing and admin paperwork, and helping you earn more stable income with higher rates. With Headway, you can finally focus on what matters most: providing life-changing care. We'll take care of the rest.
Service Team Coordinator - Inbound Call Center Agent (Healthcare) (Remote)
ChenMed · Centralia, WA
We're unique. You should be, too. We're changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy? We'redifferent than most primary care providers. We're rapidly expanding and we need great people to join our team. The Service Team Coordinator is responsible for outbound and inbound customer service call handling related to patient scheduling, general inquiries and other patient sales and service call interactions. The incumbent in this role is accountable for providing excellent customer service as they approach each interaction as an opportunity to support better patient health. He/She supports initiatives and medical centers across all ChenMed entities by assisting with key business functions of the department and medical centers and serving patients according to corporate policies and regulations. This incumbent is also responsible for achieving departmental quality, compliance and productivity standards while delivering VIP level customer service. ESSENTIAL JOB DUTIES/RESPONSIBILITIES: • Operating in a call center environment, receives inbound and makes outbound customer service calls related to patient scheduling, and other general inquiries. • Responds to patient inquiries based on the ChenMed core model for care. • Escalates issues/concerns as appropriate. • Makes appropriate and timely decisions according to department standards, procedures and policies. • Documents interactions using web-based technology. • Maintains business relationship by providing prompt and accurate service to promote loyalty. • Interacts and collaborates with team members across multiple departments to promote VIP customer service and patient interactions. • Performs other duties as assigned and modified at manager's discretion. KNOWLEDGE, SKILLS AND ABILITIES: • Competent-level business acuity • Comprehensive knowledge and understanding of general/core job-related functions, practices, processes, procedures, techniques and methods • Exceptional verbal communication skills including active listening • Excellent organizational and multi-tasking skills • Passion for serving others, particularly seniors, with initiative-taking solutions • Ability to successfully operate in a demanding environment • Proficient in keyboarding as well as, Microsoft Office Suite products including Word, Excel, PowerPoint and Outlook; competent in other systems required for the position • Availability and willingness to work overtime hours as requested by leadership and based on the staffing needs of the business • Spoken and written fluency in English; bilingual a plus (Spanish, Creole, Vietnamese preferred) EDUCATION AND EXPERIENCE CRITERIA: • High school diploma or GED equivalent required • A minimum of 2 years of customer service experience required; in a call center or similar environment • A minimum of 1 year experience working in a fast paced medical office or healthcare setting, highly preferred • Must reside in the continental United States and within a state were the company is established as a business entity • Experience with web-based customer relationship management systems PAY RANGE: $17.0 - $24.26 Hourly The posted pay range represents the base hourly rate or base annual full-time salary for this position. Final compensation will depend on a variety of factors including but not limited to experience, education, geographic location, and other relevant factors. This position may also be eligible for a bonuses or commissions. EMPLOYEE BENEFITS We're ChenMed and we're transforming healthcare for seniors and changing America's healthcare for the better. Family-owned and physician-led, our unique approach allows us to improve the health and well-being of the populations we serve. We're growing rapidly as we seek to rescue more and more seniors from inadequate health care. ChenMed is changing lives for the people we serve and the people we hire. With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow. Join our team who make a difference in people's lives every single day. Current employees, if you want to apply to our internal career site, please click HERE ( Current Contingent Worker please see job aid HERE to apply #LI-Remote
Utilization Management Nurse (84124)
Regency Integrated Health Services · Centralia, WA
Utilization Management Nurse RIHS Austin Regional Office - Austin, TX 78727 Overview Position Type Full Time Description Primary Responsibilities The Utilization Management Nurse will determine the medical appropriateness of inpatient and outpatient services by evaluating medical guidelines, benefit determination and compliance with state mandated regulations. Essential Functions • Perform concurrent, retroactive and pre-service authorization reviews for inpatient and outpatient services. • Follow and maintain compliance with CMS requirements, may include after-hours, holiday and weekend coverage. • Collaborate with staff, physicians, care/service coordinators, and medical directors to coordinate and provide the level of care necessary to meet member's health need. Qualifications Location Requirements This position is remote but requires the employee to live within our service area, which can include any of the following areas within Texas: Rio Grande Valley, DFW, greater Austin, greater Houston, greater San Antonio, Coastal Bend, or Laredo. Educational/Training Requirements • Graduate from an Accredited School of Nursing. Bachelor's degree in Nursing preferred. 2+ years of clinical nursing experience. • Payor Utilization Management: 3 years recommended experience • Proficiency with Microsoft Office applications, specifically Word, Excel, and Outlook • Proficiency using Milliman Care Guidelines (MCG) and/ or InterQual criteria. Licensing Requirements • Current unencumbered LVN or RN license in Texas or compact license. Experience Requirements • 2+ years Utilization management experience with a health insurance company (managed care/payer experience required). • UM for Medicare Advantage, Managed Medicaid, Dual SNP Lines of Business, on the payer side. • 5+ years of acute clinical experience. • The ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/families. Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear. Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.