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
Provides clinical and regulatory expertise in the review of
denial supporting documentation and member and physician
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
Performs data analysis and develops reports to identify
opportunities for improvement.
Assists in the determination of goals and priorities for the RUC
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
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.
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
Graduate of accredited school of nursing.
License, Certification, Registration
Current California RN license required.
Knowledge of NCQA, CMS, DMHC, DHCS and other local, state, and
federal requirements for member and practitioner notification of a
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
Familiarity with interpreting benefits and coverage
Ability to accommodate a flexible working schedule.
Must be able to work in a Labor Management Partnership
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
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