Job #: 6768
Title: Utilization Review Nurse
Job Location: Renton, Washington - United States
Salary: $45.00 - $48.00 - US Dollars - Hourly
Employer Will Recruit From: Local
Relocation Paid?: NO
WHY IS THIS A GREAT OPPORTUNITY?
Enjoy developing a new position for a division of a large healthcare organization. you will be acting as a liaison between Doctors and the Appeals team. You will be interpreting case information. There are 12 people on the team. You will act as a "trainer" in this position to find best practices, be proactive to question infomration and provide strategic thinking for processes. JOB DESCRIPTION
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. QUALIFICATIONS
Works within the appeal department assisting appeal coordinators and specialist with interpreting clinical notes, identifying missing clinical information and educating staff on appropriate documentation/summaries required for physician review. Acts as a liaison between appeals staff and physicians within the scope of the appeal process. Works with physicians, staff and management to create standards and address process improvements. Readily answers questions from appeals staff and helps to differentiate medical necessity issues from procedural or regulatory items.
Minimum Education Requirements
Associates Degree Nursing.
Bachelor`s Degree Nursing (with additional training in Health Plan Review and Utilization Management).
Minimum Knowledge/Skills Requirements
Basic or limited working knowledge and understanding of coding and accreditation requirements.
Intermediate proficiency using MS Word, Excel, Outlook and LAN-based systems in a Windows environment.
Excellent listening, writing and speaking communication skills.
Basic or limited understanding of medical necessity review, case management, and quality management.
Basic or limited knowledge of CPT, ICD, HCPCs and CMS coding and billing principles; medical contracts and coverage.
Intermediate knowledge of regulatory and certification requirements impacting code review, utilization management, case management, referral management and care coordination program design.
Minimum Experience Requirements
2 years Clinical practice experience.
Minimum License/Certifications Requirements
At time of hire Current Washington State RN license.
University - Associate`s Degree/Graduate Diploma/2 Years
How to Apply: