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.
Works directly with all levels of Home Care Service clinical and administrative leadership to identify and address gaps in knowledge, process and systems as they affect clinical, quality and compliance outcomes.
Identifies gaps in 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 project manager to close clinical, quality, educational and compliance gaps.
Reviews member complaints to identify potential quality issues that should be referred to the local Quality teams.  
Develops resources and implements solutions for all levels of Home Care staff. Ensures action plans are carried out, tracked and completed.
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.
Assists in the development of appropriate policies relating to compliance, clinical and quality.
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 Home Care department and organization.  
Produces or oversees development of written materials for various peer groups, functional staff, and high-level audiences. Plans and facilitates meetings.
Makes formal presentations to various audiences as pertinent to Home Care Services.
Works with KFHP/KFH, Medical Group departments and Senior Leadership at the regional, and local levels as consultant on policy and procedures, rollouts, etc.  
Coordinates the audit process, including reviewing, analyzing, and reporting findings internally to the Director, Executive Director and local agency leadership/quality committees.
Leads, makes significant contributions, and/or provides technical leadership to high visibility projects to identify and resolve issues of strategic importance to the organization.
Interfaces regularly with senior management to produce timely and valuable results.
Basic Qualifications: Experience

Minimum five (5) years of nursing staff, consultant or management experience in ambulatory, inpatient or care at home settings.
Education
Graduate of accredited school of nursing required.Registered Nurse degree required. License, Certification, Registration Registered Nurse License (California)
Additional Requirements:
Personal transportation required for local Service Area travel.May require some travel to the Service Areas and/or Regional offices across the Division.Excellent interpersonal, verbal and written communication skills.Demonstrated conflict resolution and mediation skills with ability to secure action from persons outside their supervision.Ability to work with peers in self-managed teams to meet deadlines.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. Preferred Qualifications:
Minimum five (5) years of nursing staff, consultant or management experience in home health, hospice and home palliative care settings.BSN or BA in health related field, preferred.