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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.

Authorization RN - UM, On Call, Silver Spring Customer Service Center

Location: Silver Spring, MD Job Number: 706339 Date posted: 06/12/2018
Description: Responsible for initiating and consistently evaluating the appropriateness of member/patient level outpatient specialty referrals; maintaining the efficiency and integrity of the referral process, and to monitor the quality of outcomes with a primary focus on outpatient Specialty service referral processing.

Essential Responsibilities:
  • Serve as a subject matter resource to members of the Health Care Team to advise, evaluate, interpret and educate regarding all aspects of outpatient Specialty referral processing (i.e., clinical review, information request, etc.). Ability to independently clarify, review, interpret and advise regarding outpatient Specialty referral services and benefit eligibility status using established clinical guidelines applicable to referral processing management in accordance with Health Plan policies and procedures to ensure appropriate administration of benefits. Serve as subject matter resource to identify issues and barriers that may delay timely referral processing and communicate information to all affected parties. Performs medical necessity review for outpatient Specialty referrals and initiates the denial process according to UM policy when indicated. Seeks clarification of incomplete or illegible records (i.e. inpatient, outpatient, contracting physician office records etc.) and reports problems for corrective action to Physician/Manager. Documents calls regarding referral processing in accordance with protocols. Maintains confidentiality of patient records, information, and departmental activities involving patient information in compliance with regulatory agencies. Informs and educates members of their rights. Schedules and sets work priorities while being sensitive to time and resource constraints. Maintains current knowledge of and seeks opportunities for continued education in areas of expertise. Seeks managerial guidance prospectively in cases with high cost potential where benefit management is an alternative and when quality or utilization issues will have a financial impact on the organization.
  • Collaborates with MAPMG physicians, Network physicians and other members of the Health Care Team to ensure appropriate outpatient Specialty referral services are coordinated at the appropriate level of care. Interacts with physicians and provides recommendations based on clinical history, assessment, screening and evaluation to influence actions and decisions in cases where a physician needs assistance to expeditiously process outpatient Specialty referrals and related services.
  • Provides outpatient Specialty referral processing/Utilization Management training for members of the Health Care Team and other relevant personnel. Contributes to the development of protocols, procedures, patient education, and training, as assigned. Focuses utilization review activities on targeted areas as identified by the Regional UM Committee and Quality Improvement Committee and modifies work activities accordingly. Trains and orients assigned personnel and alerts manager to potential difficulties and/or situations. Participates in departmental activities related to education, staff meetings, and guidelines and policy development.
  • Maintains the data integrity and authorization process of applicable applications (i.e., Tapestry, RMS, HealthConnect System, K-Mate, CMS website, Google, O'Neil, DIAMOND etc). Collaborates with other Kaiser Permanente staff by assisting with routine department functions.
  • Performs other related duties as directed.

  • Mon, Tue, Wed, Thu, Fri, Sat, Sun, Variable, weekend rotation, holiday rotation.
    This PRN Auth RN position will support members care coordination with some care referral processing, DME referral processing and outpatient specialty referral processing.
    The training for these support areas will be a part of the on-boarding and training orientation process.
    Current location is Silver Spring, MD at Customer Service Center and future location will be at the new administrative building in New Carrollton, MD.

    Basic Qualifications:
  • Three (3) years of clinical evaluation experience.
  • N/A
    License, Certification, Registration
  • RN license in jurisdiction where assigned is required.

    Additional Requirements:
  • Proficiency in the use of applicable computer software is required
  • Demonstrated ability to effectively and clearly present information through the written word, to influence and/or persuade others and to actively listen is required.
  • Demonstrated ability to write clearly, legibly and effectively; to present ideas and document activities; and to read and interpret written information is required.
  • Ability to effectively communicate.
  • Ability to conform to established policies and procedures.
  • Ability to analytically problem solve and make decisions.
  • Ability to tolerate and cope with ambiguity and multi-tasking.
  • Ability to work as a team member.
  • In order to work effectively with patients, must have effective interpersonal and communication skills and be able to stand, walk, bend, and lift at least 50 pounds, hear, speak and see.

    Preferred Qualifications:
  • Utilization management experience is preferred.
  • BSN is preferred.

    Primary Location: Maryland,Silver Spring,Customer Service Center 11900-A Bournefield Wy. Scheduled Weekly Hours: 1 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri, Sat, Sun Working Hours Start: 8:30 AM Working Hours End: 5:00 PM Job Schedule: Call-in/On-Call Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: UFCW - Local 400 Job Level: Individual Contributor Job Category: QA / UR / Case Management Department: Utilization Management 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.
  • About QA, Ur & Case Management Careers

    Careers In QA, Ur & Case Management

    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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