Care Review Clinician II

Title: Medical Claims Review Nurse

Duration: 3 months (Temp to Hire)

Location: Spokane, WA

Responsibilities:

· Non-exempt employee, 40 hours per week. Hours of operation 6 am – 5 pm. The manager is open for the employee to pick their start time as long as they know they must complete and 8 hour shift. They can choose.

· This not remote, in office.

· Production Guidelines after training- manager does 100% review of case on the first 2 months, so they receive feedback and then after that, they are audited monthly on a percentage of their caseloads and given feedback on the audited cases.

· Managers are looking for candidates with clinical experience from a hospital (Preferred)

· Min. 2- 3 years clinical nursing experience

· 1 year of utilization review or medical claim review

· RN License Required

· Preferred Experience in one of more of the following areas critical care, emergency medicine, surgical, paediatrics, advanced practice nursing, and billing and coding experience

· Great organizational skills

· Critical thinkers and the ability to make decisions using clinical background/knowledge

· Able to work independently

· Able to collaborate and work with peers to make decisions

· Knowledge of state and federal regulations

· In-depth Knowledge of ICD-9, CPT, and HCPTS

· Great Verbal and Written Communication Skills because they will be interacting with Medical Directors.

· Interviews: Phone screen and if it goes well then an in person interview

Knowledge/Skills/Abilities:

• Demonstrated ability to communicate, problem solve, and work effectively with people.

• Excellent organizational skill with the ability to manage multiple priorities.

• Work independently and handle multiple projects simultaneously.

• Knowledge of applicable state, and federal regulations.

• In depth knowledge of Interqual and other references for length of stay and medical necessity determinations.

• Experience with NCQA.

• Ability to take initiative and see tasks to completion.

• Computer Literate (Microsoft Office Products).

• Excellent verbal and written communication skills.

• Ability to abide by policies.

• Ability to maintain attendance to support required quality and quantity of work.

• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).

• Skilled at establishing and maintaining positive and effective work relationships with co-workers, clients, members, providers and customers.

Required Experience:

• Minimum 2-4 years of clinical practice. Preferably hospital nursing, utilization management, and/or case management.

• Required Licensure/Certification: Active, unrestricted State.

Kind Regards

Sumit Agarwal

732-902-2125