Care Review Clinician II

Care Review Clinician II

Integrated Resources, Inc is a premier staffing firm recognized as one of the tri-states most well-respected professional specialty firms. IRI has built its reputation on excellent service and integrity since its inception in 1996. Our mission centers on delivering only the best quality talent, the first time and every time. We provide quality resources in four specialty areas: Information Technology (IT), Clinical Research, Rehabilitation Therapy and Nursing.

Job Description

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.