Begin Your Search Here

Nursing Jobs in Puyallup, WA

RN Pre-Service Clinical Review - Per Diem - Must Live in WA or ID

apartment Kaiser Permanente location_onRenton, WA

** Highly Prefer Utilization Management, Case Management, Medical Necessity Review, Preauthorization Work Experience ** Must Live in Washington State or Idaho Job Summary: Reviews coverage requests using established timelines and all relevant clinical information for appropriate coding, medical necessity, care coordination, place of service, and care rendered. Summarizes findings and facilitates appropriate authorization or payment. Prepares information for review by the physician reviewer according to established procedures. Determine if new services are experimental or investigational and whether the service requires a new medical technology assessment by Kaiser Foundation Health Plan of Washington. Identifies potential fraud, waste and abuse and evaluates claims to validate. Essential Responsibilities: Conducts clinical review of coverage request based on the application of medical necessity criteria, understanding of individual coverage contracts and ability to meet Kaiser Foundation Health Plan of Washington, coding rules and other regulatory standards. Uses clinical information available in medical records and treatment summaries as a foundation to complete these reviews. Documents the above review process and decisions for determination of coverage and submits questions or potential denials to the physician review staff. Conducts these reviews while meeting regulatory standards for review timeliness. Conducts audits of claims that are suspended because of potential coding issues or high cost against established coding and billing principles. Provides consultation to requesting providers related to medical review, review criteria and coordination of care. Assures consistency and equity in access to medical benefits. Collects data to ensure appropriate reporting occurs related regulatory guidelines and decision consistency. Participates in the development and maintenance of performance and work force planning data. Supports the development and implementation of new criteria or changes in existing criteria through identification (research on the web) and reporting occurrences. Researches and supports the medical determination for experimental and investigational service requests. Works closely with the referral staff regarding medical necessity; provider relations staff regarding contract terms; and coverage and benefits staff regarding clarity and interpretation of contract language. Contacts the requesting physician by phone when required to provide notification of determination outcomes. Coordinates patient care working with treating providers and Kaiser Foundation Health Plan of Washington Case Managers. Understands and complies with medical protocols, referral processes and claims submission processes.

Outpatient

Per Diem

RN Case Manager Liaison Nurse - Outpatient Complex Care Mgmt - Per Diem Must Live in WA or ID

apartment Kaiser Permanente location_onRenton, WA

PER DIEM - RN CASE MANAGER LIAISON NURSE - OUTPATIENT COMPLEX CASE MANAGEMENT SUPPORTING BOTH NEXT STEPS CARE AND COMPLEX CARE - MUST LIVE IN WA OR ID (ABLE TO DRIVE TO SPOKANE IF IN IDAHO) TRAVEL WOULD BE LOCAL UP TO 50% MAX TO CLOSEST LOCAL KAISER MEDICAL CENTERS IN WASHINGTON STATE Job Summary: The Care Manager will work in 2 settings on a periodic rotating schedule, planning the discharges and follow up care for Kaiser Foundation Health Plan of Washington patients hospitalized at a nearby network facility and carrying a case load of patients in one of the Kaiser Foundation Health Plan of Washington medical centers. Some weekends and holidays are required, and scheduled days of the week are variable. Primary responsibility is to focus on achievement of optimal patient health care outcomes while ensuring appropriate utilization of health care resources. Working closely with primary care teams, specialty care teams and medical providers, the Liaison Nurse will establish a collaborative plan of care to assure adherence to the medical plan, improvement in functional status, and improved ability to self manage. Serves as the liaison across the internal KFHPW care continuum and between KFHPW and all externally contracted providers, facilities, and resources and provides feedback to the organization regarding the service and quality of contracted services. The Liaison Nurse collects data and provides input to leadership regarding issues or concerns related to utilization, cost, quality, service and care delivery to patients. Essential Responsibilities: Ensures patients referred to case management meet established case management criteria. Assess all patients referred for case management to determine physical, mental, financial, psychosocial status, utilizing comprehensive, standardized criteria to identify existing and potential needs. Develop patient centered case management plan based on assessments and including patient goals, objectives, and outcomes with specific time frames (long/short term). Evaluate ability and availability of designated caregiver(s) to provide patient support. Coordinate and implement interventions using evidence based guidelines. Recommend additional services to PCP as determined in the case management plan. Conduct ongoing assessment of progress against original goals. Continuously update needed services. Maintain ongoing communication with patient/family and care team. Acts as an advocate for patient care needs. Documents all responses of patient to case management interventions. Collaborates with other health care professionals regarding the plan of care, variances in plan implementation, achieved outcomes or expected outcomes. Monitor and evaluate short and long term patient responses to therapeutic interventions and analyze patterns of variance from clinical information and outcomes. Recommend alternative settings for care based on health care needs and appropriate utilization of health care resources. Document interventions and interactions with patients or caregivers according to GH and Care Management policy and procedure. Participate in the measurement of the effectiveness of the case management program. Directs and guides the plan of care to result in a seamless continuum of care. Facilitates as needed, referrals for home health care, long term care, hospice, and other care facilities or services. Participation in care conferences to provide problem solving for patients with complex care needs (limited basis). Collects needed data needed to evaluate the effects of care coordination on quality outcomes, fiscal parameters, patient satisfaction and systems improvement. Understands and utilizes health plan requirements and patient benefits in making care management decisions. Assists patient to understand and comply with their medical treatment plan. Supports patient education and activation through referral to specific chronic illness classes, group visits or community resources.