Pre-Service Clinical Review Nurse (Per Diem) Must Live in WA or ID

Essential Responsibilities: Pursues effective relationships with others by proactively providing resources, information, advice, and expertise with coworkers and members. Listens to, seeks, and addresses performance feedback; provides mentoring to team members. Pursues self-development; creates plans and takes action to capitalize on strengths and develop weaknesses; influences others through technical explanations and examples. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; helps others adapt to new tasks and processes. Supports and responds to the needs of others to support a business outcome. Completes work assignments autonomously by applying up-to-date expertise in subject area to generate creative solutions; ensures all procedures and policies are followed; leverages an understanding of data and resources to support projects or initiatives. Collaborates cross-functionally to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports, identifies, and monitors priorities, deadlines, and expectations. Identifies, speaks up, and implements ways to address improvement opportunities for team. Provides high-quality consultation by: facilitating and communicating with physicians, managers, staff, members, and/or caregivers regarding requirements related to medical necessity and benefit denials across the continuum of care; and leveraging comprehensive knowledge to ensure the correct and consistent application, interpretation, and utilization of member health care benefits, cost of care options, and coverage by members and physicians. Supports education and compliance initiatives by: remaining up-to-date and sharing information with the team on the relevant state and federal regulations, guidelines, criteria, and documentation requirements that affect utilization management; and supporting the development and delivery of education and training programs for staff and physicians at the local level to promote best practices in utilization management. Assists in quality improvement efforts by: conducting standard data analyses and developing reports to identify utilization patterns, trends, and opportunities for improvement; providing input and participating in the implementation of corrective action plans to address deficiencies in utilization review workflows/processes; actively adhering to utilization policies, procedures, and guidelines to ensure compliant and cost-effective care; and developing and refining desk-level procedures (e.g., workflows).Performs utilization reviews by: following standard policies and procedures when conducting reviews of medical records and treatment plans to evaluate the medical necessity, appropriateness, and efficiency of requested health care services; and assessing the ongoing need for services, proactively identifying, anticipating, and escalating potential issues/delays to internal team members, and recommending appropriate actions for moderately complex member cases.

Knowledge, Skills and Abilities: (Core) Ambiguity/Uncertainty Management Attention to Detail Business Knowledge CommunicationCritical Thinking Cross-Group Collaboration Decision Making DependabilityDiversity, Equity, and Inclusion Support Drives Results Facilitation SkillsHealth Care Industry Influencing Others IntegrityLearning Agility Organizational Savvy Problem Solving Short- and Long-term Learning & Recall TeamworkTopic-Specific Communication

Knowledge, Skills and Abilities: (Functional) Medical Terminology Nursing Principles Acts with Compassion ConfidentialityConsultingCoordinationEvidence-Based Medicine Principles Leverages Technology Quality Assurance and Effectiveness Relationship Building Written Communication

Minimum Qualifications: Bachelors Degree in Nursing AND minimum three (3) years of experience in direct patient care, utilization review/management, or discharge planning in a managed care setting or a directly related field. Registered Nurse License (Washington) required at hire OR Compact License: Registered Nurse required at hire

Preferred Qualifications: Two (2) years of experience in utilization review/management. Primary Location: Washington, Spokane, Riverfront Medical Center 322 W North River Dr. Additional Locations: Washington, WASeattle, WABellevue, WATacoma, WAEverett, WAOlympia, WAFederal Way, WAScheduled Weekly Hours: 1 Shift: Day Workdays: Mon - Sun - Working Hours Start: 08:00 AM Working Hours End: 05:00 PM Job Schedule: Per Diem Job Type: Standard Worker Location: Remote Employee Status: Regular Employee Group/Union Affiliation: NUE-WA-04|NUE|Non Union Employee Job Level: Individual Contributor Department: Renton Admin Rainier - Clinical Review Unit-ClaimRgnl - 1130 Pay Range: $65.86 - $76.15 / hour