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Health Care & Hospital Operations

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Specialist, Care Management

Location: San Diego, CA Additional Locations:
Job Number: 785581 Date posted: 03/28/2019
The Permanente Federation LLC (the Federation) is the national leadership and consulting organization for the eight Permanente Medical Groups (PMGs), which, together with the Kaiser Foundation Health Plans (KFHP) and Kaiser Foundation Hospitals (KFH), comprise Kaiser Permanente. The PMGs employ almost 23,000 physicians, approximately 90,000 nurses, other clinicians and staff, and provide care to over 12.2 million Kaiser Permanente members. The Federation works on behalf of the PMGs to optimize care delivery and advance Permanente Medicine - medicine that is patient centered, evidence based, technology enabled, culturally responsive, team delivered, and physician led. The Federation, based in Oakland, California, is dedicated to serving and leading Permanente Medicine, the Permanente Medical Groups, and Kaiser Permanente in support of our patients and members. The Case Management Specialist will perform telephonic advocacy services for members requiring assistance understanding their benefits, pre-certification requirements and provider network options and provides project management support under the guidance of the Director, Care Management. Reports to Director, Care Management.

Essential Responsibilities:

- Provides telephonic member advocacy services for members requesting assistance in understanding their benefits, pre-certification requirements and provider network options.
- Educate members on tiered benefit structures and subsequent financial implications to allow more informed decisions about their coverage.
- Assists in the notification to members and providers of precertification approvals.
- Refers appropriate requests for services to the Utilization Nurse and approves those within scope per established guidelines.
- Identify per program criteria and refer appropriate members to case management, disease management, risk management and quality improvement.
- Utilization and documentation in multiple internal and external systems to process referrals, identify eligibility, interpret benefits and identify Kaiser Permanente, contracted and/or non-contracted providers.
- Interprets and analyzes multi-tiered benefits and claims accumulators for appropriate utilization of services during pre-certification process.
- Leverages existing assets, resources and process to ensure optimal outcomes are achieved.
- Grasps essential facts, data and guidelines to process auto-authorizations and inform providers and/or members of decision.
- Assist members in understanding and accessing care within the Kaiser Permanente delivery system:
- Facilitate channeling to maximize benefits and continuity of care
- Facilitate appointment scheduling
- Facilitate and obtaining/transferring of medical records
- Facilitate and obtaining of test results
- Collaborate with Kaiser Permanente Regional customer services, claims, pharmacy benefits, or other operations managers as necessary to facilitate care and improve patient experience.
- Trains and mentors internal Permanente Advantage staff and Kaiser Permanente Regional customer service staff on multi-tiered benefits and claims accumulators for non-HMO plans.
- Assists in preparing denial and non-coverage member and/or provider letters.
- Communicates denials and/or non-coverage services to members and providers, ensuring timely notification.
- Advise members and/or providers of appeal and grievance process. Facilitates member and/or provider appeals once request is received and ensures timely turn around decisions to maintain regulatory compliance.
- Assists case managers and utilization nurses in follow-up calls to physicians, providers and/or members to promote timely provision of services.
- Interacts with physicians and staff and other healthcare providers as necessary to gather information as needed.
- Processes and data entry incoming pre-certification (via telephonic or fax) requests.
- Assists Care Management Medical Director in outbound calls and assistant duties as needed.
- Establishes relationships and communicates with members, family, physicians and staff, inpatient and outpatient providers, case managers, utilization nurses, member-s services, claims contract, benefits, appeals, and risk and quality departments.
- Other duties as assigned.
Basic Qualifications:


- Minimum five (5) years of customer service and utilization operations experience in a hospital or insurance company setting.
- Minimum two (2) years of experience in a Preferred Provider Organization.


- Associates degree.

License, Certification, Registration

- Certification in medical terminology.

Additional Requirements: 

- Experience with and understanding of Point-of-Service and PPO benefits, deductibles, co-pays and out of pocket financial responsibilities.
- Experience with URAC and/or NCQA accreditation process.
- Travel as required (approximately [ 1-10%] of time)
- Position will be located in San Diego, CA.

- Excellent knowledge of CPT, ICD-9 and other related manuals/reference materials.
- Excellent organizational, oral and written communication, problem solving and decision making skills.
- Superior organizational and planning skills, with demonstrated ability to multi-task, balance priorities, set and manage timelines for deliverables.
- Must possess strong customer service orientation with the ability to recognize, understand and meet the needs and expectations of the all customers within the organization.
- Ability to work independently and in collaboration with larger teams and/or stakeholders.
- Strong analytical, problem solving and critical thinking skills with attention to detail and accuracy.
- Proficiency in Windows and Microsoft Office applications (Word, PowerPoint, and Excel).

Preferred Qualifications:

- Thorough knowledge and/or experience in the health care industry and managed care, and/or Kaiser Permanente strongly preferred.
- Kaiser Permanente experience a plus.
Primary Location: California,San Diego,Kaiser Permanente On Call @ Copley 5855 Copley Dr. Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon-Fri Working Hours Start: 9:30 AM Working Hours End: 6:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: Non-Union, Non-Exempt Job Level: Individual Contributor Job Category: Healthcare / Hospital Operations Department: Permanente Advantage 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.

About Health Care & Hospital Operations Careers

Health Care & Hospital Operations Careers

Envision the future, inspire change, and deliver results. Put your talents to work not just at a powerful business, but at an organization dedicated to empowering the health and well-being of millions. As a valued member of the Kaiser Permanente team, your visionary and strategic contributions are especially vital to our success. Come drive change within the organization and across the future of health care.

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