Care Coordinator - Inpatient RN

Workforce Classification:

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The Care Coordinator - Inpatient RN performs reviews of admissions and concurrent stay requests for acute hospitalizations, skilled nursing, and inpatient rehabilitation by applying their clinical knowledge and critical thinking skills, along with established criteria and protocols, to determine the medical appropriateness of the clinical requests from providers and facilities. The incumbent partners with Medical Directors and other Premera Departments to ensure appropriate cost-effective care across all lines of business and all geographic regions.

This role follows a regular Monday through Friday schedule, working hours from 8:00 AM to 5:00 PM Pacific Time, with a rotating Saturday shift about once every quarter.

What you will do:

• Performs medical necessity review that includes inpatient review, concurrent review, benefits advisory/prior authorization, retrospective, out of network, and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, member eligibility, benefits, and contracts
• Consults with Medical Directors when care does not meet applicable criteria or medical policies
• Documents clinical information completely, accurately, and in a timely manner
• Meets or exceeds production and quality metrics
• Maintains a thorough understanding of the Plan's provider contracts, member contracts, authorization requirements and clinical criteria including Milliman care guidelines and medical policy
• Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case management, engagement team, and disease management)
• Collaborates, educates, and consults with Customer Service/Claims Operations, Sales and Marketing and Health Care Services to ensure consistent work processes and procedural application of clinical criteria
• Maintains a thorough understanding of accreditation and regulatory requirements, and ensures these requirements are accurately followed and Utilization Management (UM) decision determinations and timeliness standards are within compliance
• Supports the Plan's Quality Program: Identifies and participates in quality improvement activities as it relates to internal programs, processes studies, and projects

What you will bring:

• Bachelor's degree or four (4) years’ work experience (Required)
• Current State Licensure as a registered nurse where licensing is required by State law (Required)
• Three (3) years of clinical experience (Required)
• Utilization Management experience (Preferred)
• Experience working in the health plan industry (Preferred)

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