Kaiser Permanente Pre-Services Clinical Review RN in Spokane, Washington

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 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:


Minimum two (2) years of cllinical practice experience.


Associate's degree in nursing.

License, Certification, Registration

Current Washington State RN license by date of hire/transfer.

Additional 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.

Working knowledge and understanding of coding and accreditation requirements.

Preferred Qualifications:

Three (3) years of clinical practice experience.

Two (2) years experience in utilization/quality management.

Two (2) years of experience in medical code review.

Experience with medical necessity review, contracts and coverage determinations.

Bachelor's degree in nursing

Training in health plan review and utilization management.

AAPC Certified Professional Coding certificate by date of hire/transfer.

Knowledge of CPT, ICD, HCPCs and CMS coding and billing principles; medical contracts and coverage.

Knowledge of regulatory and certification requirements impacting code review, utilization management, case management, referral management and care coordination program design.


TITLE: Pre-Services Clinical Review RN

LOCATION: Spokane, Washington


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.