Primary Location Renton, Washington
Worker Location Remote
Job Number 1330378
Date posted 01/15/2025
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.
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- 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.
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- 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.
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- 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.
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- 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.
- Minimum three (3) year of clinical practice experience.
- Associates degree in nursing.
- Registered Nurse License (Washington) required at hire OR Compact License: Registered Nurse required at hire
- Basic Life Support required at hire
- Working knowledge and understanding of coding and accreditation requirements.
- Proficiency using MS Word, Excel, Outlook and LAN-based systems in a Windows environment.
- Excellent listening, writing and speaking communication skills.
- Understanding of medical necessity review, case management, and quality management.
- 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: Mon, Tue, Wed, Thu, Fri, Sat, Sun
Working Hours Start: 08:00 AM
Working Hours End: 05:00 PM
Job Schedule: Part-time
Job Type: Standard
Worker Location: Remote
Employee Status: Temporary
Employee Group/Union Affiliation: NUE-WA-04|NUE|Non Union Employee
Job Level: Individual Contributor
Department: Renton Admin Rainier – Grp Reltn-Review Svcs Mgt/Supp – 1130
Pay Range: $43.07 – $55.74 / 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 and a candidate’s years of relevant work experience, education, certifications, skills, and geographic location.
Travel: No
Remote: Work location is the remote workplace (from home) within KP authorized states.
Worker location must align with Kaiser Permanente’s Authorized States policy.
At Kaiser Permanente, equity, inclusion and diversity are inextricably linked to our mission, and we aim to make it a part of everything we do. We know that having a diverse and inclusive workforce makes Kaiser Permanente a better place to receive health care, a more supportive partner in our communities we serve, and a more fulfilling place to work. Working at Kaiser Permanente means that you agree to and abide by our commitment to equity and our expectation that we all work together to create an inclusive work environment focused on a sense of belonging and wellbeing.
Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.