Description: Job Summary:
Provides/gathers clinical expertise for areas of compliance which involve medical necessity and/or quality concerns. Utilizes clinical expertise to conduct investigations and seek input from other clinical professionals as required. Acts as a liaison, problem-solver, and negotiator to achieve resolution on member requests and appeals. Responsible for reviewing and analyzing audit related reports and providing consultation on non-compliance.

Essential Responsibilities:

Works directly with Member Services organization and other clinical and administrative leadership to investigate and facilitate resolution of complex and high profile member requests and appeals.  Provides/gathers clinical expertise for areas of compliance which involve medical necessity and/or quality concerns.  Interprets clinical cases (grievances and appeals including lab values, medical records and interpretation) and presents appropriate clinical material for Physician review. Reviews member complaints to identify potential quality issues that should be referred to the local Quality Departments. Provides direct support and consultation on corrective actions developed by departments for areas of non-compliance to ensure the compliance issue(s) is adequately addressed. Utilizes clinical expertise to conduct investigations and seek input from other clinical professionals as required.  Acts as a liaison, problem-solver, and negotiator to achieve resolution on member requests and appeals. Leads and/or represents Regulatory Compliance at routine and ad hoc meetings on specific compliance areas relating to DMHC regulations. Maintains database and provides all user groups timely notice of updates and implementation timeframes according to the regulations. Works with KFHP/KFH, Medical Group departments and Senior Leadership at divisional, regional, and local levels as consultant on Department of Managed Health Care (DMHC), Center of Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and Department of Health Services (DHS) compliance and develops, implements, tracks, and reports on work plans for correction. Participates in the development and implementation of internal audits for DMHC, CMS, NCQA, DHS, and State Programs compliance. Coordinates the audit process, including reviewing, analyzing, and reporting findings internally to the Director, Senior Leadership, and to KFHP quality committees. Assists in the development of appropriate policies relating to compliance. Participates in the development and implementation of necessary educational programs to ensure all appropriate parties are knowledgeable about their compliance responsibilities on an on-going basis. Leads, makes significant contributions, and/or provides technical leadership to high visibility projects to identify and resolve issues of strategic importance to the Standard Unit, Correspondence Center unit and organization. Interfaces regularly with senior management to produce timely and valuable results. Produces or oversees development of written materials for various peer groups and high-level audiences.  Plans and facilitates meetings. Makes formal presentations to various high-level audiences. Basic Qualifications:
Experience

Minimum 5 years experience and knowledge in subject matter area of expertise. Excellent interpersonal, verbal and written communication skills. Ability to work with peers in self-managed teams to meet deadlines. Demonstrated conflict resolution and mediation skills with ability to secure action from persons outside their supervision. Ability to use sound judgment and to handle potentially charged issues independently but with the knowledge and ability to escalate and ask for help when needed. Ability to multi-task and manage time in order to perform well on long-term projects while being flexible enough to assimilate short term projects on an on-going basis. Able to work in a Labor / Management Partnership environment. May require some travel to the Service Areas and/or Regional offices across the Division. Personal transportation required for local Service Area travel

Education

BSN or BA in health related field preferred. Graduate of accredited school of nursing required. Current California RN license required. Registered Nurse Degree required.

License, Certification, Registration

Registered Nurse License (California)

Additional Requirements:
Preferred Qualifications:

Registered Nurse Degree

Notes:

Must have Pediatric ICU experience
Quality and Data Abstraction and Interpretation experience
Virtual Pediatric ICU System experience