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Insurance & Claims

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As a member of our Claims Connect team, you'll help process and deliver the claims information Kaiser Permanente's members, providers, regulators, and customers need, and expect, from a world-class health care organization.

Clinical Review LOA RN - SMART Program, Rockville Regional Offices

Location: Rockville, MD Additional Locations:
Job Number: 758521 Date posted: 12/20/2018
Description:

Provides clinical expertise to the MAS Leave of Absence Review Program including but not limited to standardized processes for reviewing medically necessary time away from work, work place injury, and other leave of absence form requests.  Serves as a clinical resource to MAS physicians for leave of absence related form completion, requirements and certifications (e.g. FMLA/OFLA/ADA, etc) This position also includes serving as patient communication liaison as needed for complicated cases related to all aspects of the MAS Leave of Absence Review Program, including Leaves of Absence: FMLA (Family Medical Leave Act), Workers' Compensation, claims under the Americans with Disabilities Act Amendment Act (ADAAA), and employees with occupational and non-occupational injuries or illnesses. The key objectives are to maintain accurate communication and management of KP employees and KPs customer's employees on leave of absence while ensuring consistency and education regarding all aspects of the MAS Leave of Absence Review Program.



Essential Responsibilities:

  • Independently and proactively complete medical chart reviews in Kaiser Permanente HealthConnect providing recommendations for time off work to physicians and clinicians.

  • Recommend time away from work based on clinical judgment supported by relevant tools including, application of principles of the MAS Leave of Absence Review Program, utilization of evidence based guidelines and input from leave of absence management physician leads as necessary.

  • Assist in providing disability related education and feedback to physicians and clinicians with the goal of decreasing the variability in work absence clinical decision making and reducing the administrative burden for physicians/clinicians.

  • Communicate effectively when working with physicians and clinicians to address leave of absence related questions.

  • Research complex clinical situations utilizing available guidelines, resources and disability management physician leads.

  • Monitor and track FMLA certifications, disability forms, and work place injury forms utilizing secure departmental databases to support continuous clinical quality improvement, eliminating re-work and improving leave of absence systems and processes.

  • Support MAS goals and objectives for leave of absence prevention and management to include case management of KP employees who are injured on the job.

  • Obtain feedback regarding customer service concerns and communicate to appropriate personnel; following through to assure that identified customer and patient issues are satisfactorily addressed.

  • Develop and maintain expertise in federal, state and local leave of absence related regulations and legislation.

  • Assist with physician/clinician education and contribute to program development:

  • Collaborate with others in the interdisciplinary healthcare team to ensure that regulatory and compliance standards are met.

  • Participate in quality and inter-rater reliability review activities.

  • Assist with ensuring that regulatory and compliance standards are met in applying leave of absence prevention and management principles.

  • Contribute to the development and updating of leave of absence related training and education materials.

  • Participate in professional committees/task forces as needed/requested.

  • Collaborate with Release of Information department (ROI) in addressing leave of absence related form completion issues and requests as needed.

  • Other duties as assigned.

  • Basic Qualifications:

    Experience

  • Minimum of two (2) years' work experience as an RN.

  • Education

  • Bachelor's degree required, OR four (4) years of experience in in a directly related field.

  • High School Diploma or General Education Development (GED) required.

  • License, Certification, Registration

  • Current RN License in MD, VA and DC.



  • Additional Requirements:

  • Ability to work effectively with medical staff.

  • Demonstrated customer focused service skills.

  • Ability to navigate medically relevant databases.

  • Ability to handle highly confidential and other information with discretion.

  • Proficiency in the use of electronic medical record systems such as Health Connect.

  • Professional written and verbal communication and interpersonal skills.

  • Competence with medical record review and analysis.

  • Reliable clinical judgment and appropriate application of clinical knowledge related to assessment of appropriate medical care.

  • Demonstrate the ability to identify critical issues, exercise independent judgment and function as a team member.

  • Experienced user in Microsoft Office software.



  • Preferred Qualifications:

  • Minimum five (5) years' work experience as a RN with minimum three (3) years as a RN in Kaiser Permanente in either an inpatient or outpatient setting.

  • Previous experience in Case Management

  • Comprehensive knowledge of MAS and Kaiser Permanente Health Plan policies and procedures, personnel, goals and objectives, data systems and organizational structures.

  • Mastery in electronic clinical information systems including KP HealthConnect.

  • Working knowledge of FMLA/OFLA and ADA guidelines.

  • Proven ability to establish and maintain effective working relationships at various levels.

  • Strong analytic assessment skills with ability to problem solve independently as well as demonstrated ability to function as a team member.

  • Knowledge of process improvement, research methodology and evidence based medicine.

  • Previous experience with Occupational or Rehabilitation Medicine or similar experience.

  • Additional Skills/abilities: Adaptability, Critical thinking, Superior written and oral communications, Analytical problem solving, Quality management, and Systems thinking.

  • Master's degree in Nursing.
  • Primary Location: Maryland,Rockville,Rockville Regional Offices 2101 E. Jefferson St. Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 8:00 AM Working Hours End: 4:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: Salaried, Non-Union, Exempt Job Level: Individual Contributor Job Category: Insurance / Claims Department: SMART Program Travel: No

    About Insurance & Claims Careers

    Careers in Insurance & Claims

    Our insurance and claims teams are committed to meeting customer and member expectations when it comes to the timely and accurate processing of claims, while remaining in compliance with federal, state, and local laws, as well as regulations and rules. Make an impact as you contribute to the implementation of contemporary technology in areas such as claims quality, claims operations, business analysis, processing, configuration, reporting, and more.

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