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Utilization Management Nurse

Company: Kaiser Permanente
Location: Oakland
Posted on: June 19, 2022

Job Description:

Job Summary:

Performs telephonic medical necessity reviews utilizing established and evidenced based criteria on all designated pre-certification requests, as well as targeted outpatient procedures, services and inpatient admissions. Essential duties include but not limited to prospective review of outpatient and inpatient admissions and/or services; concurrent review and discharge planning for all members admitted to acute, sub-acute and/or skilled nursing facilities; retrospective review for services not pre-certified and/or reconsiderations. In collaboration with physician and healthcare team, facilitate appropriate resource utilization within contracted and non-contracted facilities. Evaluates eligibility and benefit information and educates member and/or family, physician and interdisciplinary healthcare team as to meet the health needs of the member and minimize out of pocket costs. Identify and refer appropriate members to case management, disease management, risk management and quality improvement. Establish relationships and communicate with members, family, inpatient and outpatient providers and case managers, community resources, skilled nursing staff, members service, claims, contracts, benefits, appeals, risk and quality management.
Essential Responsibilities:

  • Must possess an active professional license to practice in a state or territory of the United States and practice within scope of practice that is relevant to the clinical area(s) addressed in initial clinical review.
  • Utilizes established criteria to perform pre-certification review for all members requiring a procedure or service or with an admission diagnosis on the targeted review list.
  • Obtains clinical data and determines medical necessity for pre-admission, admission, concurrent and retrospective review for contracted and non-contracted facilities utilizing established guidelines and/or criteria.
  • Independently identifies high risk patients in need of post-hospital care and follow-up utilizing criteria, guidelines, high risk screens and clinical judgment.
  • Performs assessment of physiological, psychosocial and functional status to facilitate early discharge planning in collaboration with patient and/or family, physician and interdisciplinary healthcare team.
  • Facilitates and coordinates discharge planning interventions along with quality of care while ensuring utilization of resources is seamless along the continuum, based on the needs of the individual patients and availability of local delivery system.
  • All referrals, pre-certification, concurrent and retrospective reviews will be performed, and the provider and member notified of the results within the regulatory required timeframe.
  • Collaborates with and provides direction to physicians, other members of multi- disciplinary healthcare team, patient and/or family in the development, implementation, and documentation of appropriate, individualized care plans to ensure continuity quality and appropriate resource utilization.
  • Educates physicians, other members of healthcare team, and patient and/or family regarding interpretation and application of Medicare, Medicaid and Health plan benefits and coverage and its interrelationships with efficient and appropriate resource utilization and member out of pocket costs.
  • Negotiates with non-contracted providers to minimize patient out of pocket costs and maximize continuity of care. Point of contact to ensure appropriate payment of claims to maximize members benefit and available dollars.
  • Investigates, prepares and refers cases not meeting established criteria and/or requiring Medical Director (QRM) review per established department guidelines.
  • Inserts appropriate physician and/or coverage language and issues letters of non - coverage to members not meeting established medical necessity criteria and ensures patient and/or family understand appeal rights and assist with alternative resources if able and available.
  • Establishes and maintains contact with patients and their families as appropriate, including the provision of education when needed.
  • Collaborates with physicians and providers to ensure that healthcare resources are provided at the appropriate level of care and in the most appropriate setting based on established criteria or guidelines.
  • Identify per program criteria and refer appropriate members to case management, disease management, risk management and quality improvement.
  • Coordinates transmission of clinical and benefit information to patient, family, physician and/or provider remaining HIPPA compliant.
  • Provide correspondence, written and verbal, in accordance to policy and procedure for members with respect to status of pre-certification and utilization review.
  • Per established protocols or triggers, reports any incidence of unusual occurrences to quality, risk and/or patient safety to the appropriate entities.
  • Remains knowledgeable of contract benefits and current, relevant state and Federal regulations, criteria, documentation requirements, Nurse Practice Act and laws that affect managed care and case/utilization management.
  • Builds effective working relationships with physicians and providers and acts as liaison with other departments.
  • Assists in the development, implementation and revision of Utilization policies, procedures, guidelines, pathways and protocols.
  • Investigates, identifies and reports problems and inefficiencies in existing systems, and recommends changes when appropriate to the Director, QRM.
  • Monitors utilization trends in the market area, keeping appropriate management informed and makes recommendations for opportunities. Initiates recommendations to facilitate improvement in quality of care and appropriate utilization and cost management.
  • Works cross-functionally with other departments in striving to meet organizational goals and objectives.
  • Other duties as assigned.
    Basic Qualifications:

    • Minimum three (3) years Utilization Management experience, to include discharge planning and quality improvement in a managed care setting.
    • Minimum three (3)years of clinical nursing.

      • Graduate of an accredited school of nursing.
        License, Certification, Registration

        • Driver's License (California)

          • Registered Nurse License (California)

            • Registered Nurse License (Virginia)

              • Registered Nurse License (Maryland)

                • Registered Nurse License (District of Columbia)

                  • Registered Nurse License (Hawaii)

                    • Registered Professional Nurse License (Georgia)
                      Additional Requirements:

                      • Working knowledge of all local, state and federal and regulatory requirements.
                      • Excellent organizational, oral and written communication and problem-solving and decision-making skills.
                      • Excellent analytical skills.
                      • Professional image and behavior.
                      • Ability to interpret financial data, calculate figures and amounts such as discounts, interest, commissions, proportions, and percentages.
                      • Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form. Ability to negotiate and/or mediate.
                      • Ability to read and interpret documents such as contracts, procedure manuals, operations and maintenance instructions. Ability to compose reports and correspondence.
                      • Excellent windows-based navigation skills.
                        Preferred Qualifications:

                        • Three (3) years Utilization Management experience in a Preferred Provider Organization preferred.
                        • Bachelors degree in Nursing or Healthcare preferred.
                        • Certified in Utilization Management or Review (or within one year of hire) preferred.
                        • Experience with URAC and NCQA accreditation process preferred.
                          PrimaryLocation : California,Oakland,1800 Harrison
                          HoursPerWeek : 40
                          Shift : Day
                          Workdays : Mon, Tue, Wed, Thu, Fri
                          WorkingHoursStart : 08:00 AM
                          WorkingHoursEnd : 05:00 PM
                          Job Schedule : Full-time
                          Job Type : Standard
                          Employee Status : Regular
                          Employee Group/Union Affiliation : NUE-PO-01-NUE-Non Union Employee
                          Job Level : Individual Contributor
                          Job Category : QA, UR & Case Management
                          Department : Po/Ho Corp - National Case Installation - 0315
                          Travel : Yes, 10 % of the Time
                          Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

Keywords: Kaiser Permanente, Oakland , Utilization Management Nurse, Executive , Oakland, California

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