Claims Nurse (RN)

First Choice Health, headquartered in Seattle, WA, is a provider-owned healthcare organization offering employers a forward-thinking alternative to traditional health insurance. We have been serving employers of all sizes and across many industries with exceptional health benefits administration for over 35 years, providing unparalleled access to a growing number of clinically integrated networks (CIN) and a traditional PPO. Alongside our Employee Assistance Program (EAP) addressing mental health and work-life balance, our services collectively support members in every step of their healthcare journeys. At First Choice Health, we are proud to deliver the personalized, quality service our clients deserve, while reducing costs and keeping their members healthy.

The Claims Nurse (RN) is primarily responsible for performing utilization review, including prior authorization and retrospective claims review, to assess for medical necessity and appropriateness of services. This role involves applying clinical expertise and judgment to ensure compliance with medical policies, InterQual guidelines, and accepted standards of care. This role also has the opportunity to create an even deeper impact within the Medical Management Department depending on the level of expertise the applicant possesses. Ideally, the applicant would act as a resource through their knowledge of clinical coding to assist the company as a whole. With some database or software experience, this position would develop and implement enhancements to our current software (CaseTrakker) to manage the workflow for both Utilization Management and Case Management. Finally, this person would have the opportunity to assist in the ongoing training of the department’s clinical staff. This is a fully remote position with opportunity for in person meetings with advanced notice.

Performs prospective, concurrent, and retrospective utilization review of clinical information to establish medical necessity, appropriateness of services, and compliance with medical policy. Performs claims review to establish medical necessity and appropriateness of services in compliance with established medical policy, community standards, and Summary Plan Documents. Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, InterQual criteria, and accepted standards of care. Refers cases requiring adverse determination of medical necessity to the Medical Director. Identifies and refers cases for stop loss, case management, fraud/abuse and subrogation as appropriate. Researches and triages clinical appeals, utilizing appropriate policies and procedures and clinical resources, to ensure timely determinations and documentation. Reviews and responds to inquiries related to clinical coding, utilizing appropriate systems, policies, procedures, and external clinical and coding resources. Provides clinical and coding knowledge to Medical Management and other departments as needed. Utilizes analytical skills to identify problems, develop solutions, and implement courses of action within departmental policies and procedures, including recognizing trends of unusual billing, clinical practices, quality of care issues, or potential fraud and abuse. Collaborates with other departments, payers, and providers to resolve claims adjudication, authorizations, quality of care, and member or provider issues. Provides training to other nurses on clinical topics, processes, and procedures. Maintains and updates the utilization management software to ensure accurate tracking and reporting of utilization review activities. Review and maintenance of code scripting for accuracy in a database platform. Participates in policy creation and maintenance. Performs other work-related duties and special projects as assigned.