POSITION SUMMARY:
The Clinical Services & Informatics Nurse Specialist is primarily responsible for performing utilization review, including prior authorization and retrospective claims review, to assess for medical necessity and appropriateness of services. This role involves applying clinical expertise and judgment to ensure compliance with medical policies, InterQual guidelines, and accepted standards of care.
This role also has the opportunity to create an even deeper impact within the Medical Management Department depending on the level of expertise the applicant possesses. Ideally, the applicant would act as a resource through their knowledge of clinical coding to assist the company as a whole. With some database or software experience, this position would develop and implement enhancements to our current software (CaseTrakker) to manage the workflow for both Utilization Management and Case Management. Finally, this person would have the opportunity to assist in the ongoing training of the department’s clinical staff.
This is a fully remote position with opportunity for in person meetings with advanced notice.
EXAMPLES OF DUTIES:
- Performs prospective, concurrent, and retrospective utilization review of clinical information to establish medical necessity, appropriateness of services, and compliance with medical policy.
- Performs claims review to establish medical necessity and appropriateness of services in compliance with established medical policy, community standards, and Summary Plan Documents.
- Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, InterQual criteria, and accepted standards of care.
- Refers cases requiring adverse determination of medical necessity to the Medical Director.
- Identifies and refers cases for stop loss, case management, fraud/abuse and subrogation as appropriate.
- Researches and triages clinical appeals, utilizing appropriate policies and procedures and clinical resources, to ensure timely determinations and documentation.
- Reviews and responds to inquiries related to clinical coding, utilizing appropriate systems, policies, procedures, and external clinical and coding resources.
- Provides clinical and coding knowledge to Medical Management and other departments as needed.
- Utilizes analytical skills to identify problems, develop solutions, and implement courses of action within departmental policies and procedures, including recognizing trends of unusual billing, clinical practices, quality of care issues, or potential fraud and abuse.
- Collaborates with other departments, payers, and providers to resolve claims adjudication, authorizations, quality of care, and member or provider issues.
- Provides training to other nurses on clinical topics, processes, and procedures.
- Maintains and updates the utilization management software to ensure accurate tracking and reporting of utilization review activities. Review and maintenance of code scripting for accuracy in a database platform.
- Participates in policy creation and maintenance.
- Performs other work-related duties and special projects as assigned.
QUALIFICATIONS:
- Registered Nurse (RN) with a current, unrestricted nursing license.
- Minimum of five (5) years of experience in utilization review, clinical documentation review, appeals, and/or claims review.
- Two to three years’ experience in the Third Party Administrator or payer-related health care industry.
- Familiarity of accreditation standards (ie. URAC) and the impact on all areas of an organization.
- Strong understanding of clinical coding (CPT, ICD-10, HCPCS) preferred.
- Experience using a variety of software applications including electronic health records, authorization review software, Encoder, and Interqual/MCG guidelines.
- Experience in policy creation and maintenance preferred.
- Experience in training other nurses on clinical topics and procedures preferred.
- Demonstrates analytical ability to identify problems, develop solutions, and implement a course of action within an acceptable interpretation of departmental policies and procedures.
- Excellent problem-solving, negotiation, and conflict resolution skills.
- Strong written, verbal, and interpersonal communication skills with varying levels of internal and external customers and medical professionals.
- Professional demeanor and ability to prioritize tasks with minimal direction.
PAY RANGE: $100,000 – $110,000
ABOUT FIRST CHOICE HEALTH:
First Choice Health, headquartered in Seattle, WA, is a provider-owned healthcare organization offering employers a forward-thinking alternative to traditional health insurance. We have been serving employers of all sizes and across many industries with exceptional health benefits administration for over 35 years, providing unparalleled access to a growing number of clinically integrated networks (CIN) and a traditional PPO. Alongside our Employee Assistance Program (EAP) addressing mental health and work-life balance, our services collectively support members in every step of their healthcare journeys.
At First Choice Health, we are proud to deliver the personalized, quality service our clients deserve, while reducing costs and keeping their members healthy.
At First Choice Health, we are proud to deliver the personalized, quality service our clients deserve, while reducing costs and keeping their members healthy.
OUR PURPOSE, VALUES & CULTURE:
Uniting providers, employers, and individuals, we deliver sustainable solutions that elevate the health and care of our communities.
CARE | TRANSPARENT | COLLABORATE | RELENTLESS | INNOVATE
We strive to uphold the above values and take steps to cultivate our culture through each one. We work as a community, guided by our values and are unified in our mission to make healthcare access easier for everyone from all walks of life. Learn more about how we foster a culture of belonging.
At First Choice Health, we believe that a culture that fosters belonging- one that accept employees for who they are, nurtures creative thinking, and appreciates different perspectives drives our success. By cultivating an environment where every voice is valued, we empower our employees to bring their best selves to work, enable us to serve our clients and communities more effectively. We work as a community, guided by our values and are unified in our mission to make healthcare access easier for everyone from all walks of life.
BENEFITS:
Taking care of our employee’s well-being is at the heart of our organization, with that we offer a wide range of benefits that to ensure our employees health are supported.
- Medical & Vision- We offer two medical plans for employees, High Deductible and PPO plan for employees to choose from.
- Dental- A dental plan through Sun Life dental is available to employees and eligible dependents.
- Health Savings Account (HSA)- Employees who enroll in our medical plan can choose to establish a health savings account if eligible. FCH makes contributions to the HSA and employees may contribute pre-tax dollars via payroll deduction up to the IRS allowable limits.
- Flexible Spending Account (FSA)- Employees may contribute pre-tax dollars through payroll deduction to a limited vision/dental FSA. Unlike with an HSA, unused FSA funds do not rollover from year to year
- Life Insurance- FCH provides life insurance benefits at no cost at a limit of two times an employee’s annual base salary (with a max of $300,000). Employees have the opportunity to purchase additional life insurance for themselves and their dependents through payroll deduction.
- Short & Long-Term Disability Insurance- FCH provides long-term and short-term disability coverage to all employees. It is a shared cost benefit where FCH pays for the long-term benefit and employees pay for the short-term benefit.
- Personal Leave and Sick Time- FCH employees enjoy the benefit of paid time off. Vacation, sick leave, and any personal leave are combined into a general annual PTO bank. PTO accruals are based on service on a pay period: 0-1 year of service – 120 hours; 1-2 years of service – 136 hours; 3 + years of service – 168 hours.
- Paid Holidays- Each employee receives 13 paid holidays. 16 hours per year are available for community services, usable in four-hour or eight-hour time blocks.
- Employee Assistance Program (EAP)- FCH recognizes that a variety of problems can disrupt personal and work life. If an employee needs professional help, they can contact the EAP, which provides confidential access to professional counseling services for help in confronting personal problems such as alcohol/substance abuse, marital and family difficulties, financial or legal troubles, or emotional distress.
- Retirement Plan 401(k)- We contribute 50% of the employee’s 401k deferral , up to a maximum of 3% of the employee’s gross salary. Eligible employees must be at least 21 years old, and be employed with FCH a minimum of 90 days.
- Profit Sharing – FCH may make annual discretionary profit sharing contributions in an amount to be determined at Plan Year end.
- Tuition Reimbursement – Employees may be eligible to receive reimbursement for continuing education for Bachelor’s program after one year of employment with the company.
- Wellness- We encourage and promote healthy behaviors through a Wellness program that offers rewards for those that participate.
- These benefits may be changed with or without notice at any given time.
PHYSICAL REQUIREMENTS:
- Ability to see and hear at normal levels with or without aid.
- Ability to sit for long periods of time.
- Finger and hand dexterity.
- Ability to bend and twist.
Access to PHI:
X Routine and limited and does not require manager approval – The duties of the
position require routine contact with a limited set of PHI that does not require manager
approval. Examples include claims adjudication.
For California employees, please review Privacy Act: