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Nurse Consultant

2 months 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 concerns. This role will investigate and resolve complex member requests and appeals, working collaboratively with Quality and Patient Safety Teams.

Key Responsibilities
  • Provide clinical expertise to investigate and resolve member requests and appeals
  • Work with KPGA Risk Management, KPGA Member Services, and Shared Service Member Services organizations to facilitate resolution
  • Interpret clinical cases and present appropriate clinical material for Physician review
  • Review member complaints to identify potential quality issues
  • Draft Quality of Care letters to contracted facilities and track responses
  • Provide direct support and consultation on corrective actions for areas of non-compliance
  • Lead and/or represent Regulatory Compliance at routine and ad hoc meetings
  • Maintain database and provide timely notice of updates and implementation timeframes
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
  • Knowledge of computer skills, data base management, and Microsoft Office
  • Excellent interpersonal, verbal, and written communication skills
  • Ability to work with peers in self-managed teams to meet deadlines
  • Demonstrated conflict resolution and mediation skills