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Regional UM Consultant, RN

Company: Kaiser Permanente
Location: Pasadena
Posted on: June 6, 2021

Job Description:


Performs day to day utilization management activities in the Regional Utilization Compliance (RUC) related to and including consultation, case review, and notification of members regarding UM coverage decisions.

Essential Responsibilities:

Provides clinical and regulatory expertise in the review of denial supporting documentation and member and physician notification.

Provides high quality, timely consultation to physicians, managers, and staff regarding requirements related to medical necessity and benefit denials across the continuum of care.

Participates in the development and delivery of education and training programs for staff and physicians at the local and regional level.

Performs data analysis and develops reports to identify opportunities for improvement.

Assists in the determination of goals and priorities for the RUC team.

Supports appropriate auditing activities and participates in the evaluation of action plan effectiveness.

Consults on the correct and consistent application, interpretation, and utilization of member healthcare benefits.

Participates in the development, implementation, and maintenance of unit policies and procedures.

Maintains knowledge and expertise on UM decision-making guidelines/criteria and participates in annual inter-rater reliability assessments.

Attends meetings, participates on committees and multi-disciplinary project teams, and works on other UM issues, systems, or processes as assigned by the manager.

Kaiser Permanente conducts compensation reviews of positions on a routine basis.

At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status.

Such changes are generally implemented only after notice is given to affected employees.

Basic Qualifications:


Minimum five (5) years of experience in direct patient care delivery/management in a managed care environment.


BSN or bachelor's degree in health care related field required.

Graduate of accredited school of nursing.

License, Certification, Registration

Current California RN license required.

Additional Requirements:

Knowledge of NCQA, CMS, DMHC, DHCS and other local, state, and federal requirements for member and practitioner notification of a denial decision.

Skilled in verbal and written communications and problem-solving; customer service orientation; critical thinking and clinical judgment.

Fundamental word processing and computer navigation skills, and the ability to interpret and use analytical data in day to day operations.

Familiarity with interpreting benefits and coverage requirements.

Ability to accommodate a flexible working schedule.

Must be able to work in a Labor Management Partnership environment.

Preferred Qualifications:

Minimum three (3) years of experience in utilization review, case management, and discharge planning preferred.

Master's degree preferred.

Primary Location: California,Pasadena,Walnut Center - Regional Offices Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri, Sat Working Hours Start: 09:00 AM Working Hours End: 05:30 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: NUE-SCAL-01|NUE|Non Union Employee Job Level: Individual Contributor Specialty: Quality Management Department: Regional Offices - Pasadena - Rgnl Hosp Admn-Quality Liaison - 0801 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.

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Keywords: Kaiser Permanente, Pasadena , Regional UM Consultant, RN, Other , Pasadena, California

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