Registered Nurse Pre-Services Clinical Review Per Diem Remote Washington State
Renton, WashingtonAt Kaiser Permanente our nurses are leaders, clinicians, researchers, innovators, and scientists who are contributing toward being an industry-leading voice for advancing evidence-based care. Whether supporting the patient directly in our hospitals or clinics, providing care at home, serving our patients through innovative virtual technology, or managing care delivery teams, Kaiser Permanente nurses utilize scientific evidence and our integrated care model to optimize the total health of our members and the communities we serve. We invite nurses who are passionate about nursing excellence, high-quality compassionate care delivery, professionalism, integrity, teamwork and patient and family centeredness to join our teams so that we can continue to sustain and build upon our culture of excellence.
- Job Type: Part-time
- Job Level: Individual Contributor
- Travel: No
Success Profile
We’re looking for Nurse Leaders who possess the following traits.
- Collaborative
- Compassionate
- Flexible
- Leadership
- Socially Conscientious
- Trustworthy
Benefits
We offer several benefits to our nurses.
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Medical, Vision & Dental
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Retirement Plans
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Educational Opportunities & Tuition Reimbursement
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Supportive Teams & Resources
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Career Growth & Development
Our Culture
At Kaiser Permanente, we cultivate an environment of compassion, integrity, trust, and open communication that helps our teams do their best work. We believe that lifelong learning will expand our knowledge so we can better serve our patients. Our practice is rooted in research and evidence-based care. Our nurses reflect the rich diversity of our members and communities and provide culturally responsive and competent care that promotes understanding of our members needs and preferences. At Kaiser Permanente, nurses are highly skilled professionals who exemplify leadership, critical thinking, and collaborative problem solving and deliver the right care, at the right time, in the right setting.
What Our People Are Saying
Kristen
Relief Charge Nurse
“Working as a nurse at Kaiser Permanente has allowed me the perfect flexible schedule so that I can volunteer as Girl Scout Leader and room parent for both my children. My kids know that I am a hardworking mother who can provide, as well as a mom who can be present and be there for them – and that means everything to me.”
Jazmin
RN, Advice Nurse
“Working for Kaiser Permanente has allowed me to take control of my future and make my goals a possibility. I feel that Kaiser Permanente allows me to keep climbing and moving. Having that ability truly makes me feel empowered.”
Stella
Registered Nurse IV
“Kaiser Permanente has taken me on a personal and educational growth journey. I am supported by a culture of excellence that allows me to be dedicated to patients and patients’ families every day at work. What an honor to be part of Kaiser Permanente.”.
Caitlin
Inpatient Lactation Consultant
“As an RN/IBCLC in Maternal Child, I’m meeting families at a pivotal time — I’m there to help launch a new family into the world. Everything I do has the potential to impact a family’s health for generations to come.”
Kimberly
Quality Coordinator RN
“In Hawaii, your community is your family — or ‘ohana.’ I am able to provide extraordinary patient-centered care to my ohana.”
David
Appointment and Advice RN
“The location is fantastic. Kaiser Permanente is all over the country. You can pick almost any environment you want – from ocean to mountain to city. You’ll still be able to contribute to our mission of providing high quality health care at a local facility.”
Shawn
BSN, RN
“I chose Kaiser Permanente because their staff and providers really show that they care about you. Also, throughout my 12 years of working here I’m always learning something new, and I’ve had many opportunities for growth and development.”
Registered Nurse Pre-Services Clinical Review Per Diem Remote Washington State
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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.
- 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.
- 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.
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. Submit Interest
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