Medical Claims Review Manager jobs in Spokane, WA

Job Summary:

At Gritman, we pride ourselves on being the premier healthcare employer on the Palouse. We bring exceptional care that’s close to home for the members of our community, We are seeking a Staff RN to join our Utilization Review/Case Management team. The Utilization Review Nurse (UR) has skills in areas of Utilization Management (UM), medical necessity and patient status determination. This includes examining medical records, treatment and interventions to assist in avoiding payment denials and optimizing reimbursements by assessing the treatment’s appropriateness effectiveness, timing and setting based on the regulatory and reimbursement requirements of various commercial and government payers. At times the UR nurse may assist in overseeing the patient discharge plan and play a role in designing after care plans.

Responsibilities:

• Evaluating patient care plans and medical necessity

• Reviewing patient medical records for compliance with healthcare standards

• Coordinating with healthcare providers to ensure appropriate patient care and status

• Liaising with insurance companies regarding coverage and approvals

• Implementing strategies to optimize healthcare efficiency and cost-effectiveness

• Educating healthcare staff about best practices in patient care and cost management

• Collaborate with nursing, physicians, admissions, fiscal, legal, compliance, coding, admitting and billing staff.

• At times the UR nurse will be required to assist the Case Management department with patients discharge and play a role in designing and implementing after care for discharge

Essential Skills:

• In-depth knowledge of healthcare policies and regulations

• Strong analytical skills for reviewing medical records and treatment plans

• Effective communication skills for collaborating with healthcare providers and insurers

• Detail-oriented approach to ensure accurate and comprehensive reviews

• Capability to work independently and make informed decisions

• Proficiency in healthcare IT systems and electronic health records (EHRs)

Requirements:

Education:

Associates or better in nursing

Experience:

Preferred:

2-3 years acute care experience

Utilization Review experience

Will train the right individual seeking to learn a new unique skill set