Utilization Review RN

Utilization Review (UR) RN – Swedish Medical Center (Part‑time, 0.7 FTE, Evening Shift, Seattle, WA) Overview The UR Nurse supports the Utilization Management program by determining patient admission status, conducting admission, concurrent, and retrospective reviews, and ensuring compliance with payer and regulatory requirements. Responsibilities Perform admission, concurrent, and retrospective UR reviews and functions to ensure appropriate data is tracked, evaluated, and reported. Determine medical necessity and admission status type based on clinical data, payer policies, and accreditation guidelines. Conduct concurrent clinical reviews to assess ongoing medical necessity. Identify, report, and refer cases for secondary review to Case Management leadership, Medical Director, or Physician Advisor. Facilitate provider documentation to reflect patient severity and risk accurately. Submit collections, authorizations for concurrent and hospital stays, and perform appeals as needed. Collaborate with providers, compliance, contracting, revenue cycle, and external Physician Advisors on medical necessity matters. Ensure adherence to state, federal laws, and reimbursement system requirements. Provide concurrent support to providers to optimize reimbursement through accurate documentation. Analyze workflow reports to assess productivity, quality, utilization patterns, and denial trends. Participate in developing and revising quality improvement initiatives for cost‑effectiveness. Coordinate education and training for staff about UR processes, regulation changes, and reimbursement trends. Provide orientation and mentoring to new staff. Escalate issues to the Case Management team or leadership promptly. Required Qualifications Bachelor’s Degree in Nursing (BSN) from an accredited nursing school. Washington Registered Nurse license upon hire. Minimum 3 years of registered nursing experience in a clinical setting. Preferred Qualifications ACM or CCM certification upon hire. Minimum 1 year of case management experience. Benefits Competitive base pay ranging from $51.43 to $79.84 per hour, with potential additional compensation including shift differentials, overtime, and bonuses. Comprehensive benefits package includes retirement 401(k) matching, health (medical, dental, vision), life & disability insurance, paid parental leave, vacation, holiday pay, and wellness resources. Equal Employment Opportunity Proved as a fully inclusive work environment, the employer is an equal-opportunity employer and actively encourages diversity and nondiscrimination. All qualified applicants will receive equal consideration regardless of race, color, gender, disability, veteran status, religion, age, creed, nationality, sexual orientation, marital status, genetic information, or any other characteristic protected by law. Application Note Applicants in Unincorporated LosAngeles County, California will be considered for employment in accordance with relevant fair‑chance ordinances. Position Details: Requisition ID: 396124 Company: Swedish Jobs Job Schedule: Part Time Career Track: Nursing Department: SS CASE MANAGEMENT Work Location: Swedish Metropolitan Park East‑Seattle, WA 1730 Minor Ave #J-18808-Ljbffr Providence Health and Services