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Job Field: Government Jobs
Location: SPOKANE, WA
Salary: $-
Job Type: Part Time

JOB SUMMARY:

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               <td align="left"><font style="font-size: 100%;">Title: Pre-Services Clinical Review LPN<BR>Location: WA - Eastern Washington-Spokane<BR>Other Locations: null<BR><BR>Reviews coverage requests using established timelines and all relevant clinical information for appropriate coding (post-service), medical necessity, 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 Group Health. Identifies potential fraud, waste and abuse and evaluates claims to validate. Ensure documentation and evaluation is complete for a smooth transition of review information between Clinical Review and the Member Appeal Departments. Conduct reviews on potential coverage denials based on the application of medical necessity criteria, understanding of individual coverage contracts and ability to meet Group Health and other regulatory standards for review timelines.<BR>Education<BR>Minimum Education Requirements<BR>Vocational School/Certificate Prog Completion of an LPN certified vocation training program<BR><BR>Preferred Education<BR>Unspecified <BR><BR><BR>Knowledge/Skills<BR>Minimum Knowledge/Skills Requirements<BR>Basic or limited Working knowledge and understanding of coding and accreditation requirements.<BR>Intermediate Proficiency using MS Word, Excel, Outlook and LAN-based systems in a Windows environment. <BR>Excellent listening, writing and speaking communication skills.<BR>Basic or limited Understanding of medical necessity review, case management, and quality management.<BR><BR>Preferred Knowledge/Skills<BR>Basic or limited Knowledge of CPT, ICD, HCPCs and CMS coding and billing principles; medical contracts and coverage.<BR>Intermediate Knowledge of regulatory and certification requirements impacting code review, utilization management, case management, referral management and care coordination program design.<BR><BR><BR>Experience<BR>Minimum Experience Requirements<BR>None Required <BR>2 years Cllinical practice experience.<BR><BR>Preferred Experience<BR>2 years Experience in medical code review. Experience with medical necessity review and contracts and coverage determinations.<BR>3 years Clinical practice experience with two years additional experience in utilization/quality management.<BR><BR><BR>License/Certifications<BR>Minimum License/Certifications Requirements<BR>At time of hire Current Washington State LPN license.<BR><BR>Preferred License/Certifications<BR>At time of hire AAPC Certified Professional Coding certificate.<BR><BR><BR><BR><BR>Group Health is an Equal Opportunity Employer committed to a diverse and inclusive workforce.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  </font></td>
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