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Member Services Clinical Consultant

Company: Kaiser
Location: Pleasanton
Posted on: May 25, 2023

Job Description:

THIS POSITION IS RESTRICTED TO EXCLUSIVE USE WITHIN THE MEMBER SERVICES DEPT.Provides/gathers clinical expertise for areas of compliance which involve medical necessity and/or quality concerns. Conducts confidential, comprehensive, clinical and administrative review of member concerns with quality of care implications. Utilizes clinical expertise to conduct investigations and seek input from other clinical professionals as required. Acts as a liaison, problem-solver, and negotiator to achieve resolution on member requests and appeals. Responsible for facilitating compliant audit outcomes. Provides Health Plan oversight mechanism for comprehensive review of member concerns.

Essential Functions:
- Works directly with Member Services organization and other clinical and administrative leadership to investigate and facilitate resolution of complex and high profile member requests and appeals.
- Conducts confidential, comprehensive, timely clinical and administrative review of active member concerns with quality of care implications and involve medical necessity.
- Conduct same reviews of randomly extracted closed cases for the purposes of inter rater reliability in order to determine consistency and congruency of reviews among all the nurses as well as accuracy.
- Collaborates with clinical peers and business partners in seeking the best outcome for the member.
- Determine if concerns meet threshold to trigger additional (peer) review by medical center quality departments.
- Writes disposition statements justifying and/or supporting decisions made to refer cases to local departments as well as statements for non referral.
- Collaborates with local and regional quality leaders and determines workflow and handoff issues. Provides recommendations on process changes to ensure the integrity of the refer-to-quality process.
- Provides direct support and consultation on corrective actions developed by departments for areas of noncompliance to ensure the compliance issue(s) is adequately addressed.
- Works with KFHP/KFH, Medical Group departments and Senior Leadership at divisional, regional, and local levels as consultant on Department of Managed Health Care (DMHC), Center of Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and Department of Health Services (DHS) compliance issues and develops, work plans for correction.
- Participates in DMHC, CMS, NCQA, DHS, and State Programs compliance surveys.
- Coordinates the audit process, including reviewing, analyzing, and reporting findings internally to the Director, Senior Leadership, and to KFHP quality committees.
- Conducts site visits to assigned areas to discuss handoff issues, process changes and modifications.
- Participates in the development and implementation of necessary educational programs to ensure all appropriate parties are knowledgeable about their compliance responsibilities on an on-going basis.
- Provides expert clinical consultation, guidance and support to Member Case Resolution Center (MCRC) case processors on medical terminology and appropriateness of investigational review contacts and content on investigational review content.
- 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 and knowledge in subject matter area of expertise.
- Graduate of accredited school of nursing required.
- High School Diploma or General Education Development (GED) required.
License, Certification, Registration
- Current California RN license required.
Additional Requirements:
- Critical Care training, case management, problem solving, interpersonal, written and oral communication, critical thinking and computer skills.
- Demonstrated conflict resolution and mediation skills with ability to secure action from persons outside their supervision.
- Must be able to work in a Labor/Management Partnership environment.
-Preferred Qualifications:
- BSN or bachelor's degree in health related field preferred.PrimaryLocation : California,Pleasanton,Pleasanton Tech Cntr Building FHoursPerWeek : 40Shift : DayWorkdays : Mon, Tue, Wed, Thu, FriWorkingHoursStart : 08:00 AMWorkingHoursEnd : 05:00 PMJob Schedule : Full-timeJob Type : StandardEmployee Status : RegularEmployee Group/Union Affiliation : NUE-NCAL-09-NUE-Non Union EmployeeJob Level : Individual ContributorJob Category : Nursing Licensed & Nurse PractitionersDepartment : Pleasanton Admin Bldg. #1 - Grp Rltn-Sales&Mrktng Integrtn - 0208Travel : NoKaiser 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.

Keywords: Kaiser, Pleasanton , Member Services Clinical Consultant, Healthcare , Pleasanton, California

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