Supervisor - Clinical Review (Full-time - Salaried/Exempt) Washington State

3 weeks ago

Spokane, United States Kaiser Full time
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.

PrimaryLocation : Washington,Spokane,Admin. Center North, Spokane
HoursPerWeek : 40
Shift : Day
Workdays : Mon, Tue, Wed, Thu, Fri
WorkingHoursStart : 08:00 AM
WorkingHoursEnd : 05:00 PM
Job Schedule : Full-time
Job Type : Standard
Employee Status : Regular
Employee Group/Union Affiliation : NUE-WA-04|NUE|Non Union Employee
Job Level : Team Leader/Supervisor
Job Category : Nursing Licensed & Nurse Practitioners
Department : Renton Admin Rainier - Grp Reltn-Review Svcs Mgt/Supp - 1130
Travel : No
Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

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