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Lead Authorization RN - UM, Regional Office - Full-time / Part-time
•30 days ago
| Hours | Full-time, Part-time |
|---|---|
| Location | Silver Spring, MD Silver Spring, Maryland |
About this job
To be responsible for the lead to initiate & consistently evaluate the appropriateness of a member/patient level of care; maintaining the efficiency & integrity of the referral process, & to monitor the quality of outcomes.
Essential Functions:
* Maintains the data integrity & authorization process of the Referral Management System (RMS), DIAMOND & PACE Systems.
* Provides urgent/emergency care management, utilization & referral management, & benefits' interpretation for attending physicians, service chiefs, area physicians & medical center managers.
* Clarifies & interprets benefit eligibility status in accordance w/ Health Plan policies & procedures to ensure appropriate administration of benefits.
* Identifies issues & barriers that may delay timely transition to the next level of care; communicate information to all affected parties.
* Utilizes national criteria & departmental guidelines to make clinical decisions for resource allocation.
* Interacts w/ physicians to influence actions & decisions in cases where a physician needs assistance to expeditiously transition a patient to the most appropriate level of care.
* Contributes to the development of protocols, procedures, patient education, & training, as assigned.
* Performs independent triage & advice on Hotline calls for members &/or ED staff caring for members in emergency care settings.
* Acts as Resource RN for the ECM physicians on duty & non-network facilities & physicians.
* Processes authorizations, short stays, IPIs, & documents clinical notes in K-MATE & PACE systems according to established policies.
* Collaborates w/ Kaiser Permanente physicians, network physicians & facilities to assure proper member placement for the appropriate level of care.
* Provides denial letters in accordance w/ state & federal regulations.
* Coordinates repatriation of Out of Area members as necessary to assure quality & cost effective medical care.
* Coordinates transports by ambulance for members transferring from one facility to another.
* Utilizes negotiation skills & expert opinion to influence financial outcomes related to hospital days, alternative care & other referred services.
* Interacts w/ claims personnel to resolve claims issues that pertain to authorizations to assure appropriate payment.
* Utilizes MACESS as a communication tool between Claims & PSC.
* Processes referrals for DME, Home Care, & SNF after hours, weekends, &, holidays.
* Acts as team leaders & medical resource for Referral Management Assistants on the Hotline.
* Performs medical necessity review for acute care & elective procedures & initiates the denial process according to UM policy when indicated.
* Focuses utilization review activities on targeted areas as identified by the QRJM department & modifies work activities accordingly.
* Provides Utilization Management training for Regional personnel, including physicians, nurses & others.
* Seeks clarification of incomplete or illegible records including inpatient, outpatient, & contracting physician office records & reports problems for corrective action to Physician Manager.
* Documents calls regarding laboratory test results in accordance w/ protocols.
* Maintains confidentiality of patient records, information, & departmental activities involving patient information in compliance w/ regulatory agencies. Informs & educates members of their rights.
* Optimizes productive working relationships by functioning as a liaison, problem solver, & consultant to community social services health care agencies.
* Collaborates w/ other Kaiser Permanente staff by assisting w/ routine department functions.
* Seeks managerial guidance prospectively in cases w/ high cost potential where benefit management is an alternative & when quality or utilization issues will have a financial impact on the organization.
* Trains & orients assigned personnel & alerts manager to potential difficulties &/or situations.
* Participates in departmental activities related to education, staff meetings, & guidelines & policy development.
* Schedules & sets work priorities while being sensitive to time & resource constraints.
* Maintains current knowledge of & seeks opportunities for continued education in areas of expertise.
* Performs other related duties as directed.
Basic Qualifications:
Experience
* Three (3) years of clinical experience with two (2) years in utilization management experience is required.
Education
* N/A
License, Certification, Registration
* RN license in jurisdiction where assigned is required.
Additional Requirements:
* Demonstrated ability to effectively and clearly present information through the written word, to influence and/or persuade others and to actively listen are required.
* Demonstrated ability to write clearly, legibly and effectively; to present ideas and document activities; and to read and interpret written information are 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.
Preferred Qualifications:
* BSN is preferred.
* Proficiency in the use of applicable computer software preferred.
Essential Functions:
* Maintains the data integrity & authorization process of the Referral Management System (RMS), DIAMOND & PACE Systems.
* Provides urgent/emergency care management, utilization & referral management, & benefits' interpretation for attending physicians, service chiefs, area physicians & medical center managers.
* Clarifies & interprets benefit eligibility status in accordance w/ Health Plan policies & procedures to ensure appropriate administration of benefits.
* Identifies issues & barriers that may delay timely transition to the next level of care; communicate information to all affected parties.
* Utilizes national criteria & departmental guidelines to make clinical decisions for resource allocation.
* Interacts w/ physicians to influence actions & decisions in cases where a physician needs assistance to expeditiously transition a patient to the most appropriate level of care.
* Contributes to the development of protocols, procedures, patient education, & training, as assigned.
* Performs independent triage & advice on Hotline calls for members &/or ED staff caring for members in emergency care settings.
* Acts as Resource RN for the ECM physicians on duty & non-network facilities & physicians.
* Processes authorizations, short stays, IPIs, & documents clinical notes in K-MATE & PACE systems according to established policies.
* Collaborates w/ Kaiser Permanente physicians, network physicians & facilities to assure proper member placement for the appropriate level of care.
* Provides denial letters in accordance w/ state & federal regulations.
* Coordinates repatriation of Out of Area members as necessary to assure quality & cost effective medical care.
* Coordinates transports by ambulance for members transferring from one facility to another.
* Utilizes negotiation skills & expert opinion to influence financial outcomes related to hospital days, alternative care & other referred services.
* Interacts w/ claims personnel to resolve claims issues that pertain to authorizations to assure appropriate payment.
* Utilizes MACESS as a communication tool between Claims & PSC.
* Processes referrals for DME, Home Care, & SNF after hours, weekends, &, holidays.
* Acts as team leaders & medical resource for Referral Management Assistants on the Hotline.
* Performs medical necessity review for acute care & elective procedures & initiates the denial process according to UM policy when indicated.
* Focuses utilization review activities on targeted areas as identified by the QRJM department & modifies work activities accordingly.
* Provides Utilization Management training for Regional personnel, including physicians, nurses & others.
* Seeks clarification of incomplete or illegible records including inpatient, outpatient, & contracting physician office records & reports problems for corrective action to Physician Manager.
* Documents calls regarding laboratory test results in accordance w/ protocols.
* Maintains confidentiality of patient records, information, & departmental activities involving patient information in compliance w/ regulatory agencies. Informs & educates members of their rights.
* Optimizes productive working relationships by functioning as a liaison, problem solver, & consultant to community social services health care agencies.
* Collaborates w/ other Kaiser Permanente staff by assisting w/ routine department functions.
* Seeks managerial guidance prospectively in cases w/ high cost potential where benefit management is an alternative & when quality or utilization issues will have a financial impact on the organization.
* Trains & orients assigned personnel & alerts manager to potential difficulties &/or situations.
* Participates in departmental activities related to education, staff meetings, & guidelines & policy development.
* Schedules & sets work priorities while being sensitive to time & resource constraints.
* Maintains current knowledge of & seeks opportunities for continued education in areas of expertise.
* Performs other related duties as directed.
Basic Qualifications:
Experience
* Three (3) years of clinical experience with two (2) years in utilization management experience is required.
Education
* N/A
License, Certification, Registration
* RN license in jurisdiction where assigned is required.
Additional Requirements:
* Demonstrated ability to effectively and clearly present information through the written word, to influence and/or persuade others and to actively listen are required.
* Demonstrated ability to write clearly, legibly and effectively; to present ideas and document activities; and to read and interpret written information are 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.
Preferred Qualifications:
* BSN is preferred.
* Proficiency in the use of applicable computer software preferred.
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