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Experience:
No experience
Employment Type:
Intern/Co-op
Posted:
2/22/2016
Job Category:
Health Care Provider
Industry:
Health Care & Medicine
SR REGL CON & CMPL ANAL
Kaiser Permanente | Oakland, California
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Job Description

Provides high quality and cost effective leadership, analytic support services and technical expertise for centralized utilization management team. Recommends procedural and systemic remedies to correct identified inabilities to comply with regulatory rules and accreditation standards. Produces or oversees the development of written educational materials for different levels of internal and external groups. Trains and coaches analyst staff within unit. Responsible for regional NIMS database management including basic programming, testing, debugging and training. Produces productivity and compliance reports for unit. Responsible for handling denial review process through investigation, preparation, and presentation of appropriate materials for internal and external monitoring and auditing. Responsible for timely denial notice and maintaining compliance.

 

Essential Functions:
Develop, implement and maintain reports, trending and graphic displays in response to Utilization action plans and RUC operations.
Maintains and updates denial notice automated system for region Liaison to technical administrators of IT systems utilized by RUC.
Primarily responsible for identifying needs and problems with systems, testing changes with systems and recommending changes to enhance productivity of unit.
Participates in the development and implementation of internal monitoring for DMHC, CMS, and State Programs compliance areas related to UM decisions and notification.
Provides expert consultation for areas of compliance which involves benefit determinations and notification.
Responsible for the development and implementation of necessary education programs to ensure all appropriate parties are knowledgeable about how to utilize Foundations Systems, benefit information resources, and all databases utilized by RUC to ensure benefit determinations are properly adjudicated and UM determinations meet regulatory requirements.
Provides regulatory expertise in the review of benefit denial supporting documentation and
member/physician notification.

Provides high quality and cost effective leadership, analytic support services and technical expertise for centralized utilization management team. Recommends procedural and systemic remedies to correct identified inabilities to comply with regulatory rules and accreditation standards. Produces or oversees the development of written educational materials for different levels of internal and external groups. Trains and coaches analyst staff within unit. Responsible for regional NIMS database management including basic programming, testing, debugging and training. Produces productivity and compliance reports for unit. Responsible for handling denial review process through investigation, preparation, and presentation of appropriate materials for internal and external monitoring and auditing. Responsible for timely denial notice and maintaining compliance.

 

Essential Functions:
Develop, implement and maintain reports, trending and graphic displays in response to Utilization action plans and RUC operations.
Maintains and updates denial notice automated system for region Liaison to technical administrators of IT systems utilized by RUC.
Primarily responsible for identifying needs and problems with systems, testing changes with systems and recommending changes to enhance productivity of unit.
Participates in the development and implementation of internal monitoring for DMHC, CMS, and State Programs compliance areas related to UM decisions and notification.
Provides expert consultation for areas of compliance which involves benefit determinations and notification.
Responsible for the development and implementation of necessary education programs to ensure all appropriate parties are knowledgeable about how to utilize Foundations Systems, benefit information resources, and all databases utilized by RUC to ensure benefit determinations are properly adjudicated and UM determinations meet regulatory requirements.
Provides regulatory expertise in the review of benefit denial supporting documentation and
member/physician notification.

Qualifications

Basic Qualifications:
Experience
Three (3) plus years of health related experience.
Education
Bachelor's degree or four (4) years of equivalent experience.
Licenses, Certifications, Registrations
N/A.

 

Additional Requirements:
Proficient with PC applications including spreadsheet, word processing, and graphics packages.
Proficient with Kaiser Mainframe systems.
Ability to effectively coordinate multiple tasks. Working knowledge of medical terminology required.
Excellent verbal and written communications skills.
Strong customer service skills.
Strong working knowledge of KFHP coverage benefits, state, federal and local regulatory agency requirements.
Ability to synthesize and analyze departmental reports.
Demonstrated ability to train various levels of staff both within and external to compliance unit.

Basic Qualifications:
Experience
Three (3) plus years of health related experience.
Education
Bachelor's degree or four (4) years of equivalent experience.
Licenses, Certifications, Registrations
N/A.

 

Additional Requirements:
Proficient with PC applications including spreadsheet, word processing, and graphics packages.
Proficient with Kaiser Mainframe systems.
Ability to effectively coordinate multiple tasks. Working knowledge of medical terminology required.
Excellent verbal and written communications skills.
Strong customer service skills.
Strong working knowledge of KFHP coverage benefits, state, federal and local regulatory agency requirements.
Ability to synthesize and analyze departmental reports.
Demonstrated ability to train various levels of staff both within and external to compliance unit.

About Kaiser Permanente

Company Description

Serving approximately 8.7 million members in nine states and the District of Columbia, Kaiser Permanente is America's leading nonprofit integrated health plan.

Kaiser Permanente's mission is to provide high-quality, affordable health care services to improve the health of our members and the communities we serve.

Our Northern California Region provides integrated health care services to approximately 3.2 million members. Approximately 4,400 physicians of The Permanente Medical Group provide services at 20 medical centers and numerous medical offices.

Company History

Founded in 1945, Kaiser Permanente is the nation’s largest not-for-profit health plan, serving more than 8.6 million members, with headquarters in Oakland, Calif. It comprises:

  1.   • Kaiser Foundation Health Plan, Inc.

  • Kaiser Foundation Hospitals and their subsidiaries

  • The Permanente Medical Groups.

At Kaiser Permanente, physicians are responsible for medical decisions. The Permanente Medical Groups, which provide care for Kaiser Permanente members, continuously develop and refine medical practices to help ensure that care is delivered in the most efficient and effective manner possible.

Kaiser Permanente’s creation resulted from the challenge of providing Americans medical care during the Great Depression and World War II, when most people could not afford to go to a doctor. Among the innovations it has brought to U.S. health care are:

  • prepaid health plans, which spread the cost to make it more affordable

  • physician group practice to maximize their abilities to care for patients

  • a focus on preventing illness as much as on caring for the sick

  • an organized delivery system, putting as many services as possible under one roof

Mission & Values

As a health care organization in the 21st century, we have a mission--to provide quality care for our members and their families, and to contribute to the well-being of our communities.

Working Here

When you bring your career to Kaiser Permanente, the work you do directly affects the health of millions. From the business people who shape our policies, to the IT professionals enabling life-saving data, to the nurses and physicians on the front line of patient care, everyone here has a role to play in the care continuum. Knowing you have a place in that process and witnessing the outcome of the work you do is empowering. It gives you a cause to stand behind. And it makes you feel proud of the work you do every day. When people witness the impact of their contributions, they excel. Together we have the power to make a difference.

Hiring Information

The first step in beginning your career search is to look for open jobs that match your skills, qualifications, and interests. Each posting includes a description of the position and the minimum required qualifications. Once you find a position you are interested in, register for an account and provide your information for consideration online.

Benefits

As an employee, you are eligible for benefits according to your full-time/part-time status and the number of hours scheduled to work per week. Benefits may vary based on your Kaiser Permanente region, position, scheduled hours, and representation by collective bargaining or employee groups, but generally include:

  • generous vacation, holiday, and sick leave

  • medical care (including prescriptions), vision, mental health, and dental care

  • disability and life insurance coverage

  • educational opportunities and tuition reimbursement

  • employee assistance programs

  • health care, dependent care, and transit spending account options

  • retirement plans

In addition, we believe in recognizing stellar performance and sponsor a variety of programs designed to reward our skilled, innovative, caring, and committed staff.

In short, at Kaiser Permanente, we understand that there is a direct correlation between happy employees and happy members. We take pride in the compassion and dedication of our employees and find many ways to reward their hard work. In return, our employees take pride in being a part of a collaborative, professional team focused on quality, service, and care.

Honors & Awards

Kaiser Permanente of Northern California has earned an "Excellent" rating from the National Committee for Quality Assurance (NCQA)-the nation's leading reviewer of health plan quality for consumers and employers. Excellent is the top rating granted by NCQA, which reviews satisfaction surveys, preventive measures, physician credentialing, member services and improvement initiatives.*

Both our Northern and Southern California regions were the only health plans in California identified by the NCQA in its list of the best health care programs in the Pacific States. (NCQA's The State of Health Care Quality 2003)

The Joint Commission on Accreditation of Healthcare Organizations accredits all Kaiser Foundation Hospitals in California.

For the seventh straight year, no other health plan has earned higher ratings from the California Cooperative Health Reporting Initiative on more measures than Kaiser Permanente. The annual ratings measure clinical quality and member satisfaction. (CCHRI Report on Quality 2003)

Our Northern California region received more three-star "Excellent" ratings than any other health plan surveyed by California's Office of the Patient Advocate on California's Quality of Care Report Card 2003-04.

* Commercial HMO and Medicare-contracted product lines: April 2003.