Health Care & Hospital Operations
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Specialist, Care ManagementLocation: San Diego, CA Job Number: 912615 Date posted: 10/01/2020
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• 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.
• Minimum two (2) years of experience in a Preferred Provider Organization.
• 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 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.
• Kaiser Permanente experience a plus.
Travel & Job Location:
Position is located in San Diego, CA. This position is currently remote.
Work Schedule: 7:30am - 6:00pm, 4 days per week - Wednesday's Off.
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.
Learn 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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