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Coverage Decision Support Unit Clinical Specialist, Oakland, Temp

Location: Oakland, CA Additional Locations:
Job Number: 825786 Date posted: 09/06/2019
Performs day to day utilization management activities in the Coverage Decision Support Unit (CDSU) related to and including consultation, case review, and notification of members regarding UM coverage decisions.

Essential Responsibilities:

  • Provides clinical and regulatory expertise in the review of denial supporting documentation and member / physician notification. Provides high quality, timely consultation to physicians, managers, and staff regarding requirements related to medical necessity and benefit denials across the continuum of care. Consults on the correct and consistent application, interpretation, and utilization of member healthcare benefits.
  • Participates in the development and delivery of education and training programs for staff and physicians at the local and regional level.
  • Performs data analysis and develops reports to identify opportunities for improvement. Assists in the determination of goals and priorities for the CDSU team. Supports appropriateauditing activities, and participates in the evaluation of action plan effectiveness.   
  • Participates in the development, implementation and maintenance of unit policies and procedures. Maintains knowledge and expertise on UM decision-making guidelines/criteria and participates in annual inter-rater reliability assessments.
  • Attends meetings, participates on committees and multi-disciplinary project teams, and works on other UM issues, systems, or processes as assigned by the manager.
  • Kaiser Permanente conducts compensation reviews of positions on a routine basis.  At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status.  Such changes are generally implemented only after notice is given to affected employees.Add Text Here

  • Basic Qualifications:


  • Minimum two (2) years of experience in direct patient care delivery/management in a managed care environment.

  • BSN or bachelor's degree in health care related field required.
  • Graduate of accredited school of nursing.
    License, Certification, Registration

  • Current California RN licensure.

    Additional Requirements:

  • Knowledge of NCQA, CMS, DMHC, MDQR, and other local, state, and federal requirements for member and practitioner notification of a denial decision.
  • Skilled in verbal and written communications and problem-solving; customer service orientation; critical thinking and clinical judgment.
  • Fundamental word processing and computer navigation skills, and the ability to interpret and use analytical data in day to day operations.
  • Familiarity with interpreting benefits and coverage requirements.
  • Ability to accommodate a flexible working schedule.
  • Must be able to work in a Labor Management Partnership environment.

    Preferred Qualifications:

  • Minimum three (3) years of experience in utilization review, case management, and discharge planning preferred.

  • Master's degree preferred.
  • Primary Location: California,Oakland,1950 Franklin 1950 Franklin Scheduled Weekly Hours: 16 Shift: Day Workdays: Variable Working Hours Start: 8:30 AM Working Hours End: 5:00 PM Job Schedule: Short Hour Job Type: Standard Employee Status: Temporary Employee Group/Union Affiliation: Non-Union, Non-Exempt Job Level: Individual Contributor Job Category: Nursing Licensed Department: Coverage Decision Support Unit Travel: No 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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    Through professional practice and leadership, nurses at Kaiser Permanente continually advance the art and science of nursing. But we recognize that what we do is more than clinical practice. We believe that every interaction — whether it is with a patient, a colleague, a physician, or anyone else — has the potential to be extraordinary. And we find that approaching our daily routine with this in mind gives each and every action new meaning and allows us to focus on the moment, empowering us to deliver expert care.

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    Physician assistants play a powerful and important role in delivering high-quality, informative care. Working directly with patients, their families, colleagues, and supervising physicians, they are vital in defining the overall care experience.

    Being a physician assistant at Kaiser Permanente is centered on promoting a healing environment — one that maintains a caring, comforting practice while honoring the unity of the whole patient: mind, body, and spirit.

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    Apr 17, 2019

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