Nurse Consultant

2 weeks 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. The ideal candidate will have a strong clinical background and excellent communication skills.

Key Responsibilities:
  • Investigate and resolve complex member requests and appeals, working with KPGA Risk Management, KPGA Member Services, and Shared Service Member Services organizations.
  • Provide clinical expertise to ensure compliance with medical necessity and quality concerns, interpreting clinical cases and presenting appropriate clinical material for Physician review.
  • Draft Quality of Care letters to contracted facilities and track responses, providing direct support and consultation on corrective actions developed by departments.
  • 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 on member requests and appeals.
  • 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 at divisional, regional, and local levels as a consultant with Center of Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and GA Department of Public Health (GADPH) compliance and develop, implement, track, and report on work plans for correction.
  • Participate in the development and implementation of internal audits for CMS, NCQA, GADPH, and State Programs compliance, coordinating the audit process, reviewing, analyzing, and reporting findings internally to the Director, Senior Leadership, and to KFHP quality committees.
  • Assist in the development of appropriate policies relating to compliance and participate 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.
  • 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, interfacing regularly with management and KPGA Operations Leaders to produce timely and valuable results.
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 with ability to secure action from persons outside their supervision.
  • Ability to use sound judgment and to handle potentially charged issues independently but with the knowledge and ability to escalate and ask for help when needed.
  • Ability to multi-task and manage time in order to perform well on long-term projects while being flexible enough to assimilate short term projects on an on-going basis.
  • Able to work in a Labor / Management Partnership environment. May require some travel to the Service Areas and/or Regional offices across the Division. Personal transportation required for local Service Area travel.
  • Strong Clinical skills.
  • Experience with chart reviews and triaging serious events.
Preferred Qualifications:
  • Bachelors Degree in health related field.

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