MUST LIVE IN WASHINGTON STATE OR IDAHO Job Summary:Directs the daily operations of Clinical Review nurses, Case Management nurses, and Code Review nursing staff. Ensures appropriate staffing levels to accomplish established regulatory parameters, customer service, quality and productivity goals. Ensures that authorization requests sent to Prior Authorization and identified post service claims are reviewed according to appropriate regulatory, coverage and clinical criteria guidelines. Ensures reviews are done in accordance with state, federal, NCQA and CMS guidelines for timeliness and documentation. Manages staff performance by using performance management tools and providing effective coaching/mentoring. Manages department workloads using daily management systems. Provides appropriate tools and training to staff, and provides timely feedback and documentation through staff meetings and one-on-one meetings. Takes appropriate disciplinary action including counseling, performance improvement plans, etc. In consultation with and under the direction of the Pre-Service Manager, hires and terminates staff as necessary.Essential Responsibilities:
Monitors and acts on daily operations of the Clinical Review, Case Management, and Code Review nursing staff using daily management systems.
Manages and monitors daily work product of the Clinical Review, Case Management and Code Review nursing staff.
Continuously mentors and coaches staff. Help identify and define tools to perform job duties.
Monitors and manages staff performance; counsels, hires, and terminates as necessary.
Monitors and adjusts staffing between Clinical Review and Case Management and cross-functionally with other departments within Pre-Service department based on the need to comply with regulatory standards.
Basic Qualifications:
Experience
Minimum two (2) years of prior leadership experience in a clinic or utilization management setting.
Education
Bachelors degree in nursing.
License, Certification, Registration
Registered Nurse License (Washington) required at hire
Basic Life Support required at hire
Additional Requirements:
Effective communication skills.
Computer skills.
Knowledge of utilization management; Knowledge of medical benefits adjudication; Use of Milliman clinical criteria; Some knowledge of appropriate coding requirements.
Some knowledge of state, federal, NCQA, and CMS regulatory requirements related to pre-authorization.
Working knowledge of authorization processing procedures and post service claims processing procedures.
Preferred Qualifications:
Thorough knowledge of utilization management and medical benefits adjudication; Direct experience using Milliman clinical criteria.
Direct knowledge of appropriate coding and billing requirements.
Thorough knowledge and experience using state, federal, NCQA, and CMS regulatory requirements.
COMPANY: KAISERTITLE: Supervisor - Clinical Review (Full-time - Salaried/Exempt) Washington StateLOCATION: Spokane, WashingtonREQNUMBER: 1280774External 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.