Job Summary:

Responsible for the overall maintenance of Clinical Review Unit regulatory standards, coordination of Clinical Review Unit workflow, and general management of reviews prior to and after the nurse and physician components. Ensure timely completion of review process, including quality management of all Clinical Review Unit work products, to include denial letters for both Clinical Review Unit activity and Care Management activity. Accountable for all Clinical Review Unit claims-related activity, including management of Options OON and PEC reviews. Coordinate with internal and external customers to ensure timely management of this activity. Maintain a high level of inter-departmental customer service with GH internal customer departments.

Essential Responsibilities:

• Responsible for managing all incoming and outgoing review data and cases, ensuring compliance with timelines, content of denial and approval files, complete documentation in the associated information systems, and ensures all written communication meets compliance and legibility standards.

• Accountable for all communication (electronic, telephonic, and written), both into and out of the Clinical Review Unit.

• Responsible for all Clinical Review Unit-related claims activity.

• Facilitates all requests for review activity to include those by the WPMG and external delivery system, community networks, and other Kaiser Foundation Health Plan of Washington partners and customers.

  Basic Qualifications:

  Experience

• Minimum two (2) years of experience in a medical administrative position utilizing MS Office software.

  Education

• Bachelors degree OR a minimum four (4) years of experience in a directly related field.

• High School Diploma OR General Education Development (GED) is required.

  License, Certification, Registration

• N/A

  Additional Requirements:

• Advanced writing skills.

• Organizational and time management skills.

• Communication, analytical, customer service and interpersonal skills.

• Medical terminology.

• Computer skills in a Windows environment to include MS Office, Lotus Notes, IBM Applications, Filenet, IPD, Vantive and Outlook.

  Preferred Qualifications:

• Three (3) years of experience in a health plan medical review setting and familiarity with utilization management programs.

COMPANY: KAISER

TITLE: Coordinator Clinical Review Unit - MUST live in KPWA market

LOCATION: Renton, Washington

REQNUMBER: 1331505

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.