Registered Nurse Pre-Services Clinical Review Utilization Management Required

Kaiser Permanente • Full-time • Renton, WA, US • 1w ago

Job Summary:

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 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.

Related Jobs

RN Clinical Documentation Second Level Reviewer (100%, days)

UW Medicine • Full-time • Seattle, WA, US • 4d ago

RN Utilization Review

Req #: 244821 Department: UW MEDICAL CENTER - CLINICAL DOCUMENTATION Posting Date: 04/09/2025 Closing Info: Open Until Filled Salary: $10,000 - $13,800 per month Shift: First Shift Notes: As an employee you will en...

4d ago

VIEW JOB

RN / REGISTERED NURSE / UTILIZATION MANAGEMENT (PER DIEM, DAYS)

UW Medicine • Per Diem • Seattle, WA, US • 2w ago

RN Utilization Review

Req #: 244028 Department: HARBORVIEW - UTILIZATION MANAGEMENT Posting Date: 03/25/2025 Closing Info: Open Until Filled Salary: $43.82 - $79.60 per hour Shift: First Shift Notes: As a UW employee, you will enjoy gen...

2w ago

VIEW JOB

QA Surgical Clinical Reviewer RN

Seattle Children’s Hospital • Full-time • Seattle, Washington, United States of America • 1m ago

RN Pediatric Utilization Review

Responsible for collecting and submitting reliable data to a national database through evaluation of patient medical information. Additional responsibilities include assessing and interpreting of patient medical informa...

1m ago

VIEW JOB

Registered Nurse (RN)

UHS • Full-time • KIRKLAND, Washington, United States • 1m ago

Responsibilities $15,000 Sign-On Bonus full time, nights! $10,000 Sign-On Bonus full time, days & evenings! Apply today to interview & meet our nursing team! Fairfax Behavioral Health...

1m ago

VIEW JOB

Registered Nurse

UHS • Part-time • KIRKLAND, Washington, United States • 3m ago

Responsibilities $15,000 Sign-On Bonus full time, nights! $10,000 Sign-On Bonus full time, days & evenings! Apply today to interview & meet our nursing team! Fairfax Behavioral Health...

3m ago

VIEW JOB

RN - Intensive Care Unit

Swedish Health Services • Full-time • Seattle, WA, US • 3d ago

RN ICU

Description RN - ICU @ Swedish First Hill Night Shift 12 Hour Shifts $10,000 Hiring Bonus and relocation for eligible external candidates who meet all conditions for payment - this is in addition to the fant...

3d ago

VIEW JOB

RN - Interventional Radiology

Swedish Health Services • Full-time • Seattle, WA, US • $45 - $84 / hour • 3d ago

Description RN - Interventional Radiology @ Swedish First Hill Full Time Day Shift $20,000 Hiring Bonus and relocation for eligible external candidates who meet all conditions for payment - this is in additi...

3d ago

VIEW JOB

RN - Operating Room

Swedish Health Services • Full-time • Seattle, WA, US • 3d ago

RN OR

Description RN - Operating Room @ Swedish First Hill Full Time 12 Hour Shifts $15,000 Hiring Bonus and relocation for eligible external candidates who meet all conditions for payment - this is in addition to...

3d ago

VIEW JOB

Clinic RN - Behavioral Health

Swedish Health Services • Part-time • Seattle, WA, US • $39 - $62 / hour • 4d ago

RN Psych Outpatient

Description Work under the direction of the Supervisor or Clinic Manager to provide basic patient care to assigned patients. Providence caregivers are not simply valued – they’re invaluable. Join our team at Swedish...

4d ago

VIEW JOB

RN / CARDIAC CATH LAB (90% FTE, DAYS)

UW Medicine • Full-time • Seattle, WA, US • 4d ago

Req #: 242919 Department: HARBORVIEW - CARDIAC CATH LAB Posting Date: 02/04/2025 Closing Info: Open Until Filled Salary: 90% of $7,596 - $13,798 per month Shift: First Shift Notes: As a UW Medicine employee you wil...

4d ago

VIEW JOB