Care Review Clinician II

Integrated Resources Inc.; Spokane (WA); On-site; USD 70,000 - 85,000; Full time

Job summary

A leading staffing firm is seeking a Medical Claims Review Nurse in Spokane, WA, for a temporary position leading to hire. The ideal candidate will have strong clinical experience, effective communication skills, and must be proficient in medical coding. This role requires a commitment to maintaining confidentiality and compliance with applicable regulations.

Qualifications

• Minimum 2-3 years of clinical nursing experience.
• 1 year of utilization review or medical claim review experience.
• Active, unrestricted licensure in the state.

Responsibilities

• Initial review of 100% of cases for two months followed by monthly audits.
• Ensure compliance with state and federal regulations.
• Manage caseload while adhering to production guidelines.

Skills

Organizational skills

Critical thinking

Communication skills

Tools

ICD-9

CPT

HCPCS coding

Job description

Integrated Resources, Inc is a premier staffing firm recognized as one of the tri-state's most well-respected professional specialty firms. IRI has built its reputation on excellent service and integrity since its inception in 1996. Our mission centers on delivering only the best quality talent, the first time and every time. We provide quality resources in four specialty areas: Information Technology (IT), Clinical Research, Rehabilitation Therapy, and Nursing.

Job Description

Title: Medical Claims Review Nurse

Duration: 3 months (Temp to Hire)

Location: Spokane, WA

Responsibilities:

• Non-exempt employee, 40 hours per week. Hours of operation 6 am – 5 pm. The start time is flexible, as long as an 8-hour shift is completed.
• This position is in-office, not remote.
• Production guidelines after training: initial review of 100% of cases for the first two months with feedback, followed by monthly audits of a percentage of caseloads with feedback.
• Preferred candidates will have clinical experience from a hospital setting.
• Minimum 2-3 years of clinical nursing experience.
• At least 1 year of utilization review or medical claim review experience.
• Experience in critical care, emergency medicine, surgical, pediatrics, advanced practice nursing, or billing and coding is preferred.
• Strong organizational skills.
• Critical thinking and decision-making abilities based on clinical knowledge.
• Ability to work independently and collaboratively.
• Knowledge of state and federal regulations.
• Proficiency in ICD-9, CPT, and HCPCS coding.
• Excellent verbal and written communication skills, especially interactions with Medical Directors.
• Interview process includes a phone screen followed by an in-person interview if successful.

Knowledge/Skills/Abilities

• Effective communication, problem-solving, and teamwork skills.
• Excellent organizational skills to manage multiple priorities.
• Ability to work independently on multiple projects.
• Deep understanding of applicable regulations and coding references.
• Experience with Interqual and other medical necessity tools.
• Knowledge of NCQA standards.
• Proactive and goal-oriented approach to tasks.
• Maintains confidentiality and complies with HIPAA.
• Builds positive work relationships.

Required Experience

• 2-4 years of clinical practice, preferably in hospital nursing, utilization management, or case management.
• Active, unrestricted licensure in the state.