Kaiser Permanente Pre-Service Clinical Review RN (Appeals) in SEATTLE, Washington

Title: Pre-Service Clinical Review RN (Appeals) Location: WA - Seattle-Renton-GH Campus - Southwest Job Number: 171090

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 Permanente.

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. Qualifications: Education Minimum Education Requirements Associates Degree Nursing. Preferred Education Bachelors Degree Nursing (with additional training in Health Plan Review and Utilization Management). Knowledge/Skills 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. Preferred Knowledge/Skills 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. Experience Minimum Experience Requirements 2 years Cllinical practice experience. Preferred Experience 2 years Experience in medical code review. Experience with medical necessity review and contracts and coverage determinations. 3 years Clinical practice experience with two years additional experience in utilization/quality management. License/Certifications Minimum License/Certifications Requirements At time of hire Current Washington State RN license. Preferred License/Certifications At time of hire AAPC Certified Professional Coding certificate.

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status. Job: RNs Bargaining Unit: WWA Admin Exempt (non-union) FTE: 1 Schedule: Full-time Shift: Day Job Days of shift: M-F Hours of shift: 8.00 Travel: No Job level: Individual Contributor Job type: Standard Employee status: Regular J2W code: NUR5E

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.