Pre-Service Clinical Review Nurse (Per Diem) Must Live in WA or ID

Kaiser Permanente; Spokane (WA); Remote; USD 91.000 - 105.000; Vollzeit

Zusammenfassung

Kaiser Permanente in Washington state is seeking a Per Diem Utilization Review NURSE III to support medical necessity determinations and discharge planning. The role requires WA/ID mobility and commutable distance to Riverfront Medical Center in Spokane.

The position focuses on consulting with physicians and care teams, applying evidence-based guidelines, and ensuring compliant, cost-effective care while maintaining strong collaboration with members and caregivers.

Qualifikationen

• Bachelors Degree in Nursing AND minimum three (3) years of experience in direct patient care, utilization review/management, or discharge planning in a managed care setting or related field.
• Registered Nurse License (Washington) required at hire OR Compact License: Registered Nurse required at hire
• Two (2) years of experience in utilization review/management preferred

Aufgaben

• Pursues effective relationships with others by proactively providing resources, information, advice, and expertise with coworkers and members.
• Completes work autonomously by applying up-to-date expertise to generate creative solutions and ensure procedures are followed.
• Provides high-quality consultation regarding medical necessity and benefit denials across the continuum of care.
• Supports education and compliance initiatives by staying up-to-date with regulations and training staff and physicians.
• Assists in quality improvement by analyzing data, identifying utilization patterns, and implementing corrective action plans.
• Performs utilization reviews by evaluating medical records and treatment plans for medical necessity and appropriateness

Kenntnisse

Attention to Detail

Critical Thinking

Communication

Problem Solving

Teamwork

Decision Making

Organizational Savvy

Learning Agility

Ausbildung

Bachelors Degree in Nursing

RN License (WA)

Jobbeschreibung

• PRIOR UTILIZATION REVIEW/UTILIZATION MANAGEMENT RN WORK EXPERIENCE HIGHLY PREFERRED! **
• MUST LIVE IN WASHINGTON OR IDAHO, COMMUTABLE DISTANCE TO KAISER PERMANENTE WASHINGTON MEDICAL CENTER **

• PER DIEM UTILIZATION REVIEW NURSE III - WASHINGTON STATE - PRE-SERVICE CLINICAL UR/UM
• PRIOR UTILIZATION REVIEW/UTILIZATION MANAGEMENT RN WORK EXPERIENCE HIGHLY PREFERRED! **
• MUST LIVE IN WASHINGTON OR IDAHO, COMMUTABLE DISTANCE TO KAISER PERMANENTE WASHINGTON MEDICAL CENTER **

Per Diem - Mon - Sun Availability - 8am-5pm

Job Summary

In addition to the responsibilities listed below, this position is also responsible for applying advanced clinical and regulatory knowledge of evidence-based guidelines, insurance policies, and clinical criteria to consult on the medical necessity, level of care, and duration of treatment required for moderately complex reviews, and collaborating with the health care team, members, and caregivers to assist in discharge planning, cost of care options, and/or coordinating and/or adjudicating referrals to appropriate services based on medical necessity.

Essential Responsibilities

• Pursues effective relationships with others by proactively providing resources, information, advice, and expertise with coworkers and members. Listens to, seeks, and addresses performance feedback; provides mentoring to team members. Pursues self-development; creates plans and takes action to capitalize on strengths and develop weaknesses; influences others through technical explanations and examples. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; helps others adapt to new tasks and processes. Supports and responds to the needs of others to support a business outcome.
• Completes work assignments autonomously by applying up-to-date expertise in subject area to generate creative solutions; ensures all procedures and policies are followed; leverages an understanding of data and resources to support projects or initiatives. Collaborates cross-functionally to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports, identifies, and monitors priorities, deadlines, and expectations. Identifies, speaks up, and implements ways to address improvement opportunities for team.
• Provides high-quality consultation by: facilitating and communicating with physicians, managers, staff, members, and/or caregivers regarding requirements related to medical necessity and benefit denials across the continuum of care; and leveraging comprehensive knowledge to ensure the correct and consistent application, interpretation, and utilization of member health care benefits, cost of care options, and coverage by members and physicians.
• Supports education and compliance initiatives by: remaining up-to-date and sharing information with the team on the relevant state and federal regulations, guidelines, criteria, and documentation requirements that affect utilization management; and supporting the development and delivery of education and training programs for staff and physicians at the local level to promote best practices in utilization management.
• Assists in quality improvement efforts by: conducting standard data analyses and developing reports to identify utilization patterns, trends, and opportunities for improvement; providing input and participating in the implementation of corrective action plans to address deficiencies in utilization review workflows/processes; actively adhering to utilization policies, procedures, and guidelines to ensure compliant and cost-effective care; and developing and refining desk-level procedures (e.g., workflows).
• Performs utilization reviews by: following standard policies and procedures when conducting reviews of medical records and treatment plans to evaluate the medical necessity, appropriateness, and efficiency of requested health care services; and assessing the ongoing need for services, proactively identifying, anticipating, and escalating potential issues/delays to internal team members, and recommending appropriate actions for moderately complex member cases.

Knowledge, Skills and Abilities: (Core)

• Ambiguity/Uncertainty Management
• Attention to Detail
• Business Knowledge
• Communication
• Critical Thinking
• Cross-Group Collaboration
• Decision Making
• Dependability
• Diversity, Equity, and Inclusion Support
• Drives Results
• Facilitation Skills
• Health Care Industry
• Influencing Others
• Integrity
• Learning Agility
• Organizational Savvy
• Problem Solving
• Short- and Long-term Learning & Recall
• Teamwork
• Topic-Specific Communication

Knowledge, Skills and Abilities: (Functional)

• Medical Terminology
• Nursing Principles
• Acts with Compassion
• Confidentiality
• Consulting
• Coordination
• Evidence-Based Medicine Principles
• Leverages Technology
• Quality Assurance and Effectiveness
• Relationship Building
• Written Communication

Minimum Qualifications

• Bachelors Degree in Nursing AND minimum three (3) years of experience in direct patient care, utilization review/management, or discharge planning in a managed care setting or a directly related field.
• Registered Nurse License (Washington) required at hire OR Compact License: Registered Nurse required at hire

Preferred Qualifications

• Two (2) years of experience in utilization review/management.

Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.

Primary Location

Washington,Spokane,Riverfront Medical Center 322 W North River Dr.

Scheduled Weekly Hours

1

Shift

Day

Workdays

Mon - Sun -

Working Hours Start

08:00 AM

Working Hours End

05:00 PM

Job Schedule

Per Diem

Job Type

Standard

Worker Location

Remote

Employee Status

Regular

Employee Group/Union Affiliation

NUE-WA-04|NUE|Non Union Employee

Job Level

Individual Contributor

Department

Renton Admin Rainier - Clinical Review Unit-ClaimRgnl - 1130

Pay Range

$65.86 - $76.15 / hour

Kaiser Permanente strives to offer a market competitive total rewards package and is committed to pay equity and transparency. The posted pay range is based on possible base salaries for the role and does not reflect the full value of our total rewards package. Actual base pay determined at offer will be based on labor market data, internal alignment, and a candidate's years of relevant work experience, education, certifications, skills, and geographic location.

Travel

No

Work Setting

Remote

Worker location must align with Kaiser Permanente's Authorized States policy.

Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.