Prior Authorization RN Reviewer

3 weeks ago

Portland, United States Kaiser Permanente Full time

Job Summary: To assist NWP clinicians, KPNW members and community clinicians in the coordination of medical services between Kaiser Permanente and community providers and facilities. Includes interfacing with NWP clinicians, community providers and members to ensure the member receives high quality, safe, efficient and timely medical services. Essential Responsibilities: Preview and preapprove requests for referral to community clinicians and/or programs for medically necessary services as requested by the NWP clinician. Work directly with the member and the community clinician to coordinate medical services within KPNW, providing accurate and timely information to the community physician and member related to requested services. Maintain knowledge base of resources available within the community and Kaiser Permanente assists with arranging for medical services in the appropriate location. With Community Medicine Integration Center leadership, insures compliance with regulatory and accrediting requirements for utilization of referred services, including NCQA, MDQR, Federal and State agencies. Maintains knowledge of Kaiser Permanente policies, procedures and benefits. Basic Qualifications: Experience Minimum two (2) years experience as a Registered Nurse. Education High School Diploma or General Education Development (GED) required. License, Certification, Registration This job requires credentials from multiple states. Credentials from the primary work state are required before hire. Additional Credentials from the secondary work state(s) are required post hire. Registered Nurse License (Washington) within 6 months of hire OR Compact License: Registered Nurse within 6 months of hire Registered Nurse License (Oregon) within 6 months of hire Additional Requirements: Demonstrated customer focused service skills. Demonstrated ability to assimilate technical information. Ability to maintain effectiveness in a busy health care environment. Ability to work effectively with all medical staff. Ability to assess complex clinical management situations, synthesize data, develop and implement action plans. Ability to handle highly confidential and other information with discretion. Progressively responsible, broad based experience with health care management. Demonstrated skills negotiating and communicating with physicians and other health care providers to assist with the coordination of services to appropriate sites and levels of care. Working knowledge of computer systems and medical care delivery systems. Preferred Qualifications: Minimum two (2) years of work experience as a Registered Nurse within Kaiser Permanente. Experience in inpatient and outpatient settings within Kaiser Permanente. Working knowledge of electronic clinical information systems, including HealthConnect and Results Reporting. Working knowledge of regulatory and accreditation requirements related to health care and health maintenance organizations. Comprehensive knowledge of Northwest Permanente and Kaiser Health Plan policies, procedures, personnel, goals, objectives, data systems and organizational structure. Bachelors degree in nursing or related field preferred. COMPANY: KAISER TITLE: Prior Authorization RN Reviewer LOCATION: Portland, Oregon REQNUMBER: 1317385 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.

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