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Kaiser Permanente Careers

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.

Manager, Post-Acute Quality Program - Hyattsville, MD

Location: Hyattsville, MD Job Number: 897867 Date posted: 12/10/2020

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The Post-Acute Clinical Quality Program Manager conducts quality oversight functions to ensure a departmental structure that facilitates superior clinical outcomes. Working with the Director, the candidate is responsible to work in collaboration with post-acute skilled nursing facility team, home care and dialysis vendor partners, MAPMG physicians and internal/external stakeholders to provide quality oversight for key post-acute utilization functions. The candidate will serve as a liaison providing quality oversight to ensure timely resolution for all member and facility concerns, implement process improvement initiatives, ensure effective departmental utilization, monitor staffing patterns, and promote seamless transitions and D/C planning.

Essential Responsibilities:
  • Conducts clinical quality reviews and root cause analysis in response to member and facility complaints; includes clinical review and outreach to internal and external stakeholders, written responses, and outreaching to members/families and facilities for timely service recovery. Prioritize time-sensitive complaints. Conducts skilled nursing facility and home care vendor related corrective actions and performance related activities. Conducts post-acute activities to discuss discharge barriers and extended length of stay cases. Conducts quality chart reviews charts for member with highest LOS; follow up with PCC, and UM MD as needed. Chart reviews. Address and follow up on barriers to SNF admission and/or discharges to include collaboration with Regional Directors, Administrators and Directors of Admission to decrease LOS.  Conducts quality review and audits regarding referral integrity, clinical documentation and discharge planning. Follow up on all QIO overturns. Consults with Kaiser internal stakeholders regarding barriers to DME, best practices, and education for skilled nursing facility staff. Facilitate oversight of quality scorecards and related quality metrics data. Attends identified internal meetings regarding quality activities, census calls, discharge planning and complex case management. Provides direct outreach to Core SNF partners to obtain quality metrics data.
  • Review of skilled nursing facility referral work queue for pending referrals, outstanding partial approvals, referral entry errors, self-funded cases and other related post-acute utilization management functions. Provides direction to staff and outreach to internal/external stakeholders regarding pending referrals and outstanding Single Case Agreements. Follow-up with inpatient hospital managers to address needed corrections, 'real-time' education regarding referral entry errors, and outstanding referrals in pending status. Review daily pended referral census to ensure corrections are made; outreach to hosp PCCs and managers regarding potential out of compliance referrals at risk for cancellation. Review 'at risk' referrals in pending status and follow up with Director and assigned PCC. Review referral errors report from compliance; ensure corrections are made. Provide oversight for DENC and DND workflows. Provide oversight to ensure compliance with documentation guidelines, monitor and education regarding inappropriate SNF admissions. Serve as a liaison to resolve denied Medicare Part B services for Kaiser custodial members.
  • Assist to manage partnership with home care vendors and Core skilled nursing facilities. Review and approve CRM work queue for single case agreements related to skilled nursing facilities and provide missing information. Collaborate with internal contracting regarding to address contract clarifications to facilitate discharge planning barriers. Provide guidance regarding custodial members and Medicare Part B services and tracking custodial members.
  • Review skilled nursing facility tracking log for possible assignment changes. Outreach to SNF PCCs regarding any assignment changes. Facilitate and arrange staff educational sessions. Coordinated FIM certification trainings of all Core Rehab Teams and SNF PCCs. Monitor staffing assignments. Supports professional growth by providing education, training, appropriate resources and provides real time coaching
  • Performs other related duties as assigned.
  • Basic Qualifications:
  • Minimum eight (8) years of clinical experience.
  • Minimum five (5) years of clinical experience in a hospital or outpatient setting.
  • Minimum five (5) years of experience in utilization management or case management activities required.
  • Education
  • BSN or BA in health care related field required, OR four (4) years of experience in a directly related field.
  • Graduate of accredited school of nursing is required.
  • High School Diploma or General Education Development (GED) required.
  • License, Certification, Registration
  • Current RN licensure in the appropriate jurisdiction required.

  • Additional Requirements:
  • N/A

  • Preferred Qualifications:
  • Master's degree in health care related field preferred.
  • CPHQ certification preferred.
  • Primary Location: Maryland,Hyattsville,New Carrollton Administration Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon - Fri Working Hours Start: 8:00 AM Working Hours End: 5:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: NUE-MAS-01|NUE|Non Union Employee Job Level: Individual Contributor Job Category: QA / UR / Case Management Department: UR Case Mgmt SNF 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.

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    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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