Registered Nurse Pre-Services Clinical Review Per Diem Remote Washington State

Health eCareers; Renton (WA); Remote; USD 80,000 - 100,000; Full time

Job summary

An established industry player is seeking a dedicated clinical reviewer to evaluate coverage requests and ensure compliance with medical necessity criteria. This role involves conducting thorough reviews of clinical information, collaborating with healthcare providers, and supporting the development of new criteria. The ideal candidate will have a strong background in nursing, excellent communication skills, and a deep understanding of coding and accreditation requirements. Join a team that values quality care and strives to make a positive impact on patient outcomes. If you are passionate about healthcare and compliance, this opportunity is perfect for you.

Qualifications

• Minimum 3 years of clinical practice experience required.
• Registered Nurse License (Washington) required at hire.

Responsibilities

• Conduct clinical reviews of coverage requests based on medical necessity criteria.
• Provide consultation to providers related to medical review and coordination of care.

Skills

Clinical Practice

Medical Necessity Review

Communication Skills

Coding Knowledge

Case Management

Education

Associates Degree in Nursing

Bachelors Degree in Nursing

Tools

MS Word

MS Excel

MS Outlook

LAN-based Systems

Job description

Job Summary:

Reviews coverage requests using established timelines and all relevant clinical information for appropriate coding, medical necessity, care coordination, place of service, and care rendered. Summarizes findings and facilitates appropriate authorization or payment. Prepares information for review by the physician reviewer according to established procedures. Determines if new services are experimental or investigational and whether the service requires a new medical technology assessment by Kaiser Foundation Health Plan of Washington. Identifies potential fraud, waste and abuse and evaluates claims to validate.

Essential Responsibilities:

1. Conducts clinical review of coverage request based on the application of medical necessity criteria, understanding of individual coverage contracts and ability to meet Kaiser Foundation Health Plan of Washington, coding rules and other regulatory standards. Uses clinical information available in medical records and treatment summaries as a foundation to complete these reviews. Documents the above review process and decisions for determination of coverage and submits questions or potential denials to the physician review staff. Conducts these reviews while meeting regulatory standards for review timeliness. Conducts audits of claims that are suspended because of potential coding issues or high cost against established coding and billing principles.
2. Provides consultation to requesting providers related to medical review, review criteria and coordination of care. Assures consistency and equity in access to medical benefits. Collects data to ensure appropriate reporting occurs related regulatory guidelines and decision consistency. Participates in the development and maintenance of performance and work force planning data.
3. Supports the development and implementation of new criteria or changes in existing criteria through identification (research on the web) and reporting occurrences. Researches and supports the medical determination for experimental and investigational service requests.
4. Works closely with the referral staff regarding medical necessity; provider relations staff regarding contract terms; and coverage and benefits staff regarding clarity and interpretation of contract language. Contacts the requesting physician by phone when required to provide notification of determination outcomes. Coordinates patient care working with treating providers and Kaiser Foundation Health Plan of Washington Case Managers. Understands and complies with medical protocols, referral processes and claims submission processes.

Basic Qualifications:

Experience

1. Minimum three (3) years of clinical practice experience.

Education

1. Associates degree in nursing.

License, Certification, Registration

1. Registered Nurse License (Washington) required at hire OR Compact License: Registered Nurse required at hire.
2. Basic Life Support required at hire.

Additional Requirements:

1. Working knowledge and understanding of coding and accreditation requirements.
2. Proficiency using MS Word, Excel, Outlook and LAN-based systems in a Windows environment.
3. Excellent listening, writing and speaking communication skills.
4. Understanding of medical necessity review, case management, and quality management.

Preferred Qualifications:

1. Four (4) years of clinical practice work experience.
2. One (1) year of experience in utilization management.
3. Experience with medical necessity review and contracts and coverage determinations.
4. Knowledge of regulatory and certification requirements impacting code review, utilization management, case management, referral management and care coordination program design.
5. Knowledge of CPT, ICD, HCPCs and CMS coding and billing principles; medical contracts and coverage.
6. Bachelors degree in nursing.
7. Training in Health Plan Review and Utilization Management.