Description: Job Summary:
Decrease plan exposure to bad faith or breach of contract lawsuits, regulatory sanctions, and adverse media by ensuring utilization review denials are completed in compliance with federal/state/contractual laws/regulations, plan policy and legal principles. Advise and assist operations managers, physicians and staff who participate in utilization review by coaching them on the appropriate review process, informing them of regulatory and accreditation requirements pertaining to timeliness, documentation and patient-physician notices, and drafting accurate denial notices.
Essential Responsibilities:
Issue written denial notices which comply with all State, Federal, and accreditation requirements, as well as contractual elements, laws or regulations related to timeliness, documentation and letter content.Provide verbal notification on medically expedited referrals in accordance with regulatory agencys requirements and department policy and procedures.Convert complex contract language and clinical criteria into easily understood and member friendly language.Assesses and responds to the needs of business partners to support a compliant notification.Collaborates with others to solve business problems; escalates issues or risks as appropriate; communicates progress and information.Supports the completion of priorities, deadlines, and expectations. Identifies and speaks up for ways to address improvement opportunities.Ensures compliance by: complying with State and Federal laws, regulations, patient rights, and professional ethics, with some guidance; upholding Kaiser policies and procedures and applicable federal and state laws and regulations, with general direction; serving as a liaison to assist other departments in complying with standard accreditation and regulatory utilization management requirements (e.g., policies and procedures Utilization Review Manager or Administrator); preparing for and participating in routine regulatory audits and related projects (e.g., quarterly to annual audits, accrediting bodies); and learning about changes to laws, regulations, codes, policies, following general guidance, and standards as they apply to utilization management.Coach department managers, physicians and staff who perform utilization review on relevant regulatory and accreditation requirements, documentation requirements and internal process. Work directly with utilization review areas such as the Regional Referral Center, Durable Medical Equipment, Mental Health, Pharmacy, Dental, Home Health, etc. to improve processes when their processes do not comply with requirements.Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work.Perform other duties as requested. Basic Qualifications: Experience
Minimum two (2) years of experience disseminating complex information (contractual, legal or regulatory) orally and in writing to customers/co-workers.Minimum one (1) year experience in position using medical terminology to review medical records, to obtain or provide information or take action.Minimum two (2) years of experience using computer systems and applications. Education
High School Diploma or General Education Development (GED) required. License, Certification, Registration N/A Additional Requirements:
Thorough knowledge of medical terminology.Basic knowledge of covered benefits and services.Working knowledge of clinical services, policies and procedures.Excellent oral communication skills; demonstrated ability to negotiate positive resolutions, defuse anger and resolve conflicts both in person and over the telephone by utilizing a variety of mediation, conflict resolution, negotiation methods.Strong writing skills; demonstrated ability to summarize complex and sensitive information, and write reports/memos/letters in a clear, concise, non-judgmental, non-threatening and effective manner.Excellent judgment, analytical and problem-solving skills; demonstrated ability to interpret contractual, legal, and regulatory material, identify important requirements, making independent decisions to develop effective recommendations.Excellent time management/prioritization skills; demonstrated ability to handle multiple tasks accurately and efficiently, with shifting priorities, successfully meeting deadlines.Ability to assimilate and apply complex and diverse state/federal regulations, accreditation requirements or similar material generally and on a case by case basis.Demonstrated experience using KP word processing programs and excellent typing skills. Preferred Qualifications:
Minimum two (2) years of Program experience; working knowledge of plan Service Agreements, operational structure/policies/procedures.Minimum two (2) years of experience working in an HMO or other health care environment in a direct service role like customer service, sales, marketing, etc.Intermediate/competent Knowledge of internal computer systems including OA/KARE/CMS/OSCAR/Epic/Results Reporting/Lotus.Basic knowledge of federal HMO/state/HCFA regulations pertaining to utilization review and appeals and provision of care/services.Basic knowledge of legal concepts, e.g., contract law, malpractice.Ability to perform simple programming.