1405179

Description:

** Highly Prefer Utilization Management, Case Management, Medical Necessity Review, Preauthorization Work Experience **

Must Live in Washington State or Idaho

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. Determine 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:

• 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.
• 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.
• 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.
• 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

• Minimum three (3) year of clinical practice experience.

Education

• Associates degree in nursing.

License, Certification, Registration

• Registered Nurse License (Washington) required at hire OR Compact License: Registered Nurse required at hire

• Basic Life Support required at hire

Additional Requirements:

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

Preferred Qualifications:

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

Primary Location: Washington,Renton,Renton Administration - Rainier Scheduled Weekly Hours: 1 Shift: Day Workdays: Sun, Mon, Tue, Wed, Thu, Fri, Sat Working Hours Start: 08:00 AM Working Hours End: 05:00 PM Job Schedule: Per Diem Job Type: Standard Worker Location: Flexible Employee Status: Regular Employee Group/Union Affiliation: NUE-WA-04|NUE|Non Union Employee Job Level: Individual Contributor Department: Renton Admin Glacier - Utilization Management - 1130 Pay Range: $44.03 - $56.95 / year 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 and a candidate's years of relevant work experience, education, certifications, skills, and geographic location. Travel: No Flexible: Work location is on-site at a KP location, with the flexibility to work from home. Worker location must align with Kaiser Permanente's Authorized States policy.