At Kaiser Permanente, we value the rich diversity of our organization and aspire always to demonstrate respect for the uniqueness of each individual.
We encourage each contribution to the establishment of an open, inclusive environment that supports and empowers our employees.
PERIOD
09/02/09-09/04/09
COLORADO INTERNAL
EMPLOYEE,
BID ON
LINE
303-614-1510,
NOT
ONLINE.
SUMMARY
Provides day to day management of a team comprised of nurses, referral processors and support staff with accountability for referral management and medical review.
Referral management includes referral entry, clinical review of referral requests and coverage determinations.
Medical Review involves review of a specific subset of claims prior to payment that may require specific payment instructions based on the contract or code requirements.
Accountable for compliance with policies and procedures, compliance with referral processing protocols, compliance with
SOX
controls, process efficiency and exceptional service to members and physicians.
Manages represented staff in compliance with Kaiser Permanente's Labor Management Partnership.
SPECIFICATIONS
Licensure as a registered nurse in the State of Colorado with at least five years of clinical experience in a hospital setting, preferably ICU, CCU, Med-Surgical.
2-3 years of progressively responsible experience in a managed healthcare environment that includes leadership and/or supervisory experience with demonstrated skills in managing human resource issues and strong decision-making skills.
Bachelor's degree, preferred in business or health care related field.
Knowledge of quality and utilization review methods.
Effective interpersonal and communication skills required.
Experience in Windows based system software programs.
Working knowledge of CMS/Medicare coverage/payment rules/guidelines and medical criteria such as Interqual or Milliman preferred.
Working knowledge of medical billing procedures and reimbursement policies, e.g.
CPT
, ICD,
APC
and
DRG
coding preferred.
Working knowledge of various health insurance products such as PPO, HMO, POS, and Indemnity preferred.
RESPONSIBILITIES
Analyzes data and facilitates issue identification and problem resolution.
Creates and maintains an effective team with accountability for an efficient, service-oriented, timely regulatory compliant and accurate process for receipt and entry of referrals into the system, clinical review, and
UM
decision making.
Insures accurate benefit and eligibility management as defined in the member's Evidence of Coverage and in compliance with state and federal regulations.
Coordinates with various internal and external customers to facilitate high quality, timely, and cost effective care and service.
Contributes to organizational planning through participation in inter and intra regional projects.
Chairs or participates on region wide teams, task forces and committees to develop recommendations on issues which can range from small, localized to broader, region wide issues with significant and critical impact.
Establishes a collaborative working relationship with appropriate managers within the organization to help identify and facilitate operational changes needed to improve and/or support functional processes dependent on the work of the referral management team, care delivery and claims payment.
Ensures that coverage determinations are made in compliance with statutes, regulations, and accreditation standards and polices.
Maintains current information and knowledge of all applicable Kaiser policies, local, state and federal laws and regulations, and accreditation standards.
Ensures that the training activities incorporate all applicable
KP
policies, local, state and federal laws and regulations, and accreditation standards.
Coordinates care with various internal and external customers to facilitate high quality, timely, and cost effective care and service.
Supervises assigned staff.
This includes interviewing, selecting, training, motivating, evaluating, counseling, disciplining and terminating in compliance with EEO/
AA
goals and personnel policies of the organization..Local travel between care centers and/or facilities required.
COMPLIANCE
(do not edit) Accountable for creating a culture of compliance, ethics and integrity.
Maintains knowledge of and assures departmental compliance with Kaiser Permanente's Principles of Responsibility and policies and procedures, and applicable regulatory requirements and accreditation standards.
Responds appropriately to observed fraud or abuse.
Maintains current information and knowledge of all applicable Kaiser policies, local, state and federal laws and regulations, and accreditation standards.
Ensures that the training activities incorporate all applicable
KP
policies, local, state and federal laws and regulations, and accreditation standards.
Supervises assigned staff.
This includes interviewing, selecting, training, motivating, evaluating, counseling, disciplining and terminating in compliance with EEO/
AA
goals and personnel policies of the organization.
Functional and Environmental Factors available upon request.
SCHEDULE
Monday - Friday 8:00
AM
- 5:00
PM
RANGE
$5,650 - $7,353 (Monthly) - Kaiser Permanente is an AA/
EEO
employer -