Job Summary
Responsible for carrying out medical necessity reviews on all designated referrals for Home Care, DME Specialty Care services. The activities will include telephonic review for medical necessity of the designated services using established criteria and guidelines for coordination of services. Eligibility and benefit reviews will be performed as necessary. Identification of patients for case management, quality improvement reviews, and communication with inpatient care coordinators, case managers, providers, Customer Service, Claims, Contracts and Benefits - Appeals, Risk Management are responsibilities of the position.
Essential Responsibilities
- Responsible for the day to day review activities as outlined above. Utilizes established criteria to perform medical necessity review for all members requiring home health and DME services. All referral reviews will be performed within the required timeframe and with adherence to the decision notification process. Refers all cases that do not meet established criteria to the appropriate review physician. Performs benefit and eligibility reviews on referrals. Provides investigation and preparation of cases requiring review of the Chief of QRM according to the established guidelines. Understands the Complex Case Management Program and referral process; Refers patients to the Complex Case Managers according to procedure. Provides correspondence in accordance to policy and procedure for members with respect to service requests. Interacts with vendors to ensure that resources are being utilized appropriately while maintaining quality outcomes.
- Establishes and maintains contact with case manager regarding requests and review status as appropriate.
- Refers the patient to the social workers as appropriate. Performs quality of care and service reviews using identified quality indicators. Reviews the utilization reports with the Supervisor to assure appropriateness of reviews and makes adjustments based on findings. Remains knowledgeable of contract benefits and current, relevant state and Federal regulations, criteria, documentation requirements and laws that affect managed care and case/utilization management. Maintains effective interaction/communication with members of the medical staff, health care teams, intake coordinators, complex case managers, social workers, inpatient care coordinators, referral coordinators, Member Services, Claims, Contracts and Benefits-Appeals, Risk Management and Kaiser Permanente medical offices to facilitate the review process. Builds effective working relationships with other department. Under the guidance of the supervisor, participates in the maintenance of all QRM policies and procedures related to the Transitional Care Review Program. Participates in call rotation to support after hours and weekend requests for quality resource management services.Refers cases identified as risk management, peer review or quality issues to QAIR and Risk Management.
- Document Review Activities according to documentation guidelines. Issue letters of non - coverage to members not meeting established medical necessity criteria. Works cross-functionally with other departments in striving to meet organizational goals and objectives. Achieves and maintains an understanding of relevant state and federal regulations, criteria, and documentation requirements and laws that affect managed care, home health and case/utilization management. Knowledgeable and compliant with regional personnel policies and procedures. Knowledgeable and compliant with QRM departmental and unit specific policies and procedures. Participates in annual regional and departmental compliance training. Knowledgeable and compliant with Principles of Responsibility. Consistently supports compliance and the Principles of Responsibility (Kaiser Permanentes Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanentes policies and procedures.
- Responsible for assisting the Medical Office Administration, Customer Services and Provider Relations in investigating concerns and issues. Access to protected health information (PHI) will be limited to the minimum necessary required to effectively perform the job. Demonstrates understanding of HIPAA privacy regulations by maintaining confidentiality of Protected Health Information (PHI). Demonstrates doing the right thing and doing things the right way is an underlying premise in all work related activities and is able to identify location of copy of Principles of Responsibility. Develops and maintains an awareness of how to report compliance issues and concerns. Identifies issues of wrong doing and promptly investigates and reports to immediate supervisor or Director of Regional Compliance. Assures an atmosphere and culture for staff to report issues of wrong doing. Other duties as assigned.
Basic Qualifications
Experience
- Minimum three (3) years of clinical nursing OR completed Kaiser Permanente Nurse Residency Program in KP Georgia.
Education
- B.S. in Nursing or four (4) years of directly related experience.
- High school diploma or GED required.
License, Certification, Registration
- Registered Professional Nurse License (Georgia)
Additional Requirements
- Working knowledge of all relevant federal, state, local and regulatory requirements, including Medicare.
- Functional knowledge of computers.
- Experience in ICD9/CPT4 coding.
- Experience in home health and durable medical equipment coordination.
- Experience with managed health care delivery systems.
Preferred Qualifications
- Minimum three (3) years of clinical nursing with preferred experience home health, rehabilitation or skilled nursing care.
- Minimum two (2) years of experience in utilization or case management, discharge planning and quality improvement in a managed care or health care setting preferred.
- Preferred experience with managed care or health care delivery systems.
- CCM preferred.
- B.S. in Nursing.