Nurse Consultant

1 week ago


Atlanta, Georgia, United States Kaiser Permanente Full time
Job Summary:

The Nurse Consultant will provide clinical expertise to ensure compliance with medical necessity and quality standards. This role will investigate and resolve complex member requests and appeals, working collaboratively with clinical and administrative teams.

Key Responsibilities:
  • Investigate and resolve complex member requests and appeals, utilizing clinical expertise and collaboration with clinical and administrative teams.
  • Provide clinical expertise to ensure compliance with medical necessity and quality standards, interpreting clinical cases and presenting appropriate clinical material for review.
  • Draft Quality of Care letters to contracted facilities and track responses, providing direct support and consultation on corrective actions for non-compliance.
  • Utilize clinical expertise to conduct investigations and seek input from other clinical professionals as required, acting as a liaison, problem-solver, and negotiator to achieve resolution.
  • Lead and/or represent Regulatory Compliance at routine and ad hoc meetings on specific compliance areas relating to GA state regulations.
  • Maintain database and provide timely notice of updates and implementation timeframes according to regulations.
  • Work with KFHP/KFH, Medical Group departments, and Senior Leadership to develop, implement, track, and report on work plans for correction, ensuring compliance with CMS, NCQA, and GADPH regulations.
  • Participate in the development and implementation of internal audits for CMS, NCQA, GADPH, and State Programs compliance, coordinating the audit process and reporting findings internally.
  • Assist in the development of appropriate policies relating to compliance, participating in the development and implementation of necessary educational programs to ensure all parties are knowledgeable about their compliance responsibilities.
  • Lead, make significant contributions, and/or provide technical leadership to high-visibility projects to identify and resolve issues of strategic importance to the Standard Unit, Correspondence Center unit, and organization.
Requirements:
  • Minimum five (5) years experience and knowledge in subject matter area of expertise.
  • Graduate of an accredited nursing program.
  • Registered Nurse Degree required.
  • Registered Professional Nurse License (Georgia) required at hire.
Preferred Qualifications:
  • Bachelors Degree in health-related field.

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