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Quality Assurance, UR & Case Management

Passion + Vision + Integrity = Excellence

Ensure consistency and the highest ethical standards across our entire organization. Our quality assurance team drives ongoing improvement by fostering an environment of support, providing technical and specialized consultative services, and inspiring ongoing excellence.

Director Case Coordination Center

Location: Downey, CA Additional Locations:
Job Number: 889414 Date posted: 07/01/2020
Description:
The CCC Director is responsible for guiding patient care and managing outside medical expenses associated with complex care in a variety of settings including out-of-plan emergency, referred, and contracted care. The highest priority is on patient safety, regulatory compliance and ensuring the quality of care received by Kaiser Permanente members transferred within Plan, out-of-Plan, both in-area and out-of-area.
This position will be responsible for the direct operational management of 1 of 3 Services (staffed by exempt professionals (Physicians (SCPMG and TPMG) and Registered Nurses) and nonprofessional ancillary staff.
  1. Emergency Prospective Review Program (EPRP): 24/7 California-wide program which coordinates member care in non-KFH Emergency Departments.  Program includes ETAP (Emergency Tertiary Assistance Program), PTAC (Pediatric Transport and Advice Center), and Teleradiology services.
  2. Outside Utilization Resource Services (OURS): 24/7 SCAL-regional program which coordinates care of members admitted (Inpatient) to non-KFH Facilities.  Program includes management of a cohort of departments including Trans-Telephonic Monitoring (TTM) service.
  3. Behavioral Health Care (BHC): 24/7 SCAL-regional program which provides member crisis counseling, facility placement, repatriation, and care coordination at KP-contracted psychiatric facilities.
  • Ensuring accurate, consistent and timely abstraction of information from the documentation performed for all CCC operations.
  • Direct, monitor, and review statistical reports for departmental activity/productivity and analyze data to identify compliance and/or noncompliance by non-plan providers to CCC operations.
  • Collaborate with department supervisor(s) and Regional Physician Leads/Partners when resolving problems, issues, and operational policies and procedures.
  • Advise CCC Leadership on the development and implementation of programs to decrease the cost of self-referred member care outside the Kaiser Permanente system.
  • Identify opportunities and enhancements for department operations.
  • Develop proposals/business cases/etc. based on identified opportunities for improvement/enhancement and present to CCC management for consideration in a clear and concise manner.

    Essential Responsibilities:
  • Provides on-going evaluation and management of staff under his/her direct supervision, including recruiting, interviewing, hiring, firing, rewarding and discipline. (Represented staff which may include clerks, utilization analysts and Registered Nurses staff 75+.
  • Directs, oversees and coordinates activities of individuals and departments, both internally and externally, to control out of plan emergency medical costs (in area and outside the service area) while ensuring that the Kaiser Permanente Health Plan (KP) members receive appropriate, focused, quality care at the out of plan facilities by non-plan physicians and providers.
  • Ensures that the treating physicians and providers have a single, immediate, contact point that provides a plan physician and/or registered nurse who is knowledgeable and immediately available to discuss and document the KP member's medical condition, presentation, treatment plan, disposition.
  • Manages the cohort of departments to ensure the efficient training, scheduling and management of the staff in a cost-effective manner.
  • Ensures consistent development and implementation of processes across the span of control and to other CCC departments. ¬†
  • Responsible for reporting, analysis and evaluation of departmental operations.
  • Ensures the coordination of repatriation activities of KP members that is safe, timely and at an appropriate level, and/or coordinates follow-up care from the non- plan facility to a plan facility, thereby ensuring the KP member's continuum of care.
  • Ensures the accurate, consistent and timely abstraction of information regarding the KP member's out of plan care and/or interactions and that this information is successfully communicated to the appropriate departments for review and/or claims adjudication.
  • Ensures that all the departmental operational activities are in compliance with the KP benefits and with the various regulatory agencies involved with the management and monitoring of medical care and reimbursement and government legislation.
  • Ensures the application of appropriate contracts and monitors the compliance by the vendors involved in the operations.
  • Ensures that the local Quality Improvement (QI) departments for the California Division - South/North are advised regarding areas of potential problems and/or services that do not seem to meet KP members' needs, which if addressed, have potential to enhance the Medical Center operations. Also, ensures that specific cases meeting the departmental QI indicators are referred appropriately to in plan and out of plan parties designated for this activity.
  • Analyzes the departmental data to identify compliance and/or noncompliance by non-plan providers and KP members. Ensures the maintenance of accurate data analyzing trends and resources utilized (claims costs by hospital, by month, outpatient vs. inpatient utilization, ambulance/Critical Care Transport (CCT)/CCT with MD utilization).
  • Advises the CCC Leadership regarding opportunities for future expansion and growth of current operational programs, as well as potential new operational activities/programs. Develop proposals to capture potential growth opportunities.
  • Advises the CCC Leadership regarding the feasibility and/or changes required to meet the needs of current and new customers for the operations.
  • Works closely with the Supervisor regarding operational issues, concerns and with the Supervisor, ACS regarding data issues and concerns to identify and resolve issues and concerns. Oversees and ensures that the activities and resources are available and effective for the Network Intensivist program operations.
  • Basic Qualifications:
    Experience
  • Minimum four (4) years of management experience.
  • Minimum five (5) years of program development and program management experience in the medical field centers/hospitals.
  • Education
  • Bachelor's degree
  • License, Certification, Registration
  • N/A

  • Additional Requirements:
  • Experience working with call centers and telephony operations.
  • Knowledge regarding requirements of the various regulatory agencies and various legislative directives affecting reimbursement, inter-facility transfers, managed care and claims management.
  • Knowledge of computers, mainframe and desktop; ability to utilize various software applications.
  • Autonomous professional.
  • Proactive, analytical, detail-oriented approach with excellent follow through, ability to do accurate analytical work under short time frames without supervision.
  • Visionary and Skilled collaborator and team builder.
  • Excellent written and verbal communication skills demonstrated.
  • Ability in planning, organizing, conflict resolution, negotiating and interpersonal skills.
  • Must be able to work in a Labor/Management Partnership environment.

  • Preferred Qualifications:
  • Minimum two (2) years utilization management experience preferred
  • Active RN licensure.
  • Graduate degree in a health care related field.
  • Primary Location: California,Downey,Downey Boeing - Independence Park 12254 Bellflower Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon - Fri Working Hours Start: 9:00 AM Working Hours End: 5:30 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: Salaried, Non-Union, Exempt Job Level: Manager with Direct Reports Job Category: QA / UR / Case Management Department: Outside Utilization Resources Services (OURS) Travel: Yes, 5 % 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.

    External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.

    About QA, Ur & Case Management Careers

    Careers In QA, Ur & Case Management

    As an organization, we are committed to delivering the same exemplary care no matter who you are, where you are, or what your needs. But how are those standards defined, measured, and assessed? That's where our quality assurance team comes in. Implementing the action plans and initiatives that will drive successful practices, you'll work across the organization to foster the necessary education, communication, and innovation that will enable us to operate as one KP — with our mission and goals in complete alignment.

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