RN Coordinator - Utilization Management ( Job Number: 174613 ) career at Kaiser Permanente in Honolulu

Kaiser Permanente is at present recruited RN Coordinator - Utilization Management ( Job Number: 174613 ) on Wed, 13 Mar 2013 01:43:56 GMT. Under indirect supervision using established guidelines, reviews eligibility, benefit and medical necessity of prospective and concurrent referrals generated by physicians of HPMG, Affiliated Practitioners and Consultants, and retrospective requests for payment; Consults with referring physicians and staff with respect to referrals and requests for retrospective coverage/authorization for benefit...

RN Coordinator - Utilization Management ( Job Number: 174613 )

Location: Honolulu Hawaii

Description: Kaiser Permanente is at present recruited RN Coordinator - Utilization Management ( Job Number: 174613 ) right now, this career will be placed in Hawaii. Further informations about this career opportunity please give attention to these descriptions. Under indirect supervision using established guidelines, reviews eligibility, benefit and medical necessity of! prospective and concurrent referrals generated by physicians of HPMG, Affiliated Practitioners and Consultants, and retrospective requests for payment; Consults with referring physicians and staff with respect to referrals and requests for retrospective coverage/authorization for benefit, appropriate providers and redirection of referrals as necessary; Assists Medical Director(s) of Affiliated Care with investigation of referrals and communicates to members and staff as appropriate; Coordinates mainland referrals and links patients to care coordinators; Identifies problems and makes recommendations for intervention.

Essential Functions:

• Maintains current knowledge of Health Plan benefits, regulatory/compliance requirements, and regional Quality Agenda; applies this knowledge in daily work processes; identifies and reports quality of care/service concerns
• Assists others in Affiliated Care Department with UM determinations and clinical c! larification
• Receives prospective and concurrent requ! ests for service; follows departmental policies and procedures for review, determination, and notification
• Applies referral guidelines; seeks physician or benefit clarification as needed; provides correspondence, written and verbal, in accordance with policies and procedures to members and providers
• Receives claims for unauthorized services; reviews and researches medical records, requesting additional documentation, etc. to validate claims or member/provider statements; assures that appropriate determination letters are issued to members/practitioners and that information is logged into Denials Tracking System
• Redirects requests/claims to Point of Service when applicable
• Interacts and communicates with outside providers to assure appropriate delivery of service to members; assists with mainland referral coordination; contacts mainland providers and links providers with patients/families; links patients to case managers which may exist wi! thin internal provider environment
• Manages members referred for extensive and/or continuation services by monitoring referral activity and outcomes; communicates to referring physicians
• Employs principles of Service Excellence and Playing to Win behaviors
• Maintains effective interactions/communication with physicians, affiliated providers, case managers, transfer coordinators and Clinic staff to assure that patients move seamlessly across continuum of care
• Participates in or conducts intra/inter-departmental and HLM meetings or task forces; communicates outcomes and developments with staff and appropriate departments
• Works collaboratively with Health Plan, HPMG and all other departments and staff within organization as well as within other Kaiser Divisions; schedules, conducts, and attends interdepartmental meetings as needed
• May Perform patient care to the extent necessary to maintain clinical expertise, competency and ! licensing necessary to fulfill job responsibilities and to direct the p! rovision of care on the unit
• Incorporates the KP Nursing Vision, Model and Values through out their Nursing Practice
• Performs other duties and accepts responsibility as assigned

Qualifications

Basic Qualifications:

• Three years health care experience
• Utilization Management/Quality Improvement experience
• Bachelor's degree in nursing
• Valid Hawaii RN License (must meet education requirement(s) for Hawaii State licensure)
• Current BLS for Healthcare Provider CPR or CPR/AED for the Professional Rescuer certification
• Valid driver's license
• Ability to work across organization and tap into resources to accomplish goals and to problem solve.
• Demonstrated knowledge of and skill in oral communication, written communication, conflict resolution, problem solving, customer service, interpersonal relations, and multi-tasking/prioritize
• Demonstrated knowledge of a! nd skill in word processing, multimedia presentations, and spreadsheet PC applications

Preferred Qualifications:

• Three years health care experience in managed care
• Knowledge of governmental indemnity, No-Fault, Worker's Comp and Health Plan insurance coverages
• Regulatory compliance as established by NCQA, HCFA, etc.

- .
If you were eligible to this career, please email us your resume, with salary requirements and a resume to Kaiser Permanente.

If you interested on this career just click on the Apply button, you will be redirected to the official website

This career starts available on: Wed, 13 Mar 2013 01:43:56 GMT

Apply RN Coordinator - Utilization Management ( Job Number: 174613 ) Here