Utilization Management Coordinator

6 days ago

Portland, Oregon, United States Kaiser Permanente Full time
Job Summary:

As a Utilization Management Member Notices Coordinator at Kaiser Permanente, you will play a critical role in ensuring compliance with federal, state, and contractual laws and regulations. Your primary responsibility will be to review and process utilization review denials, ensuring that they are completed in accordance with all applicable laws, regulations, and plan policies.

You will work closely with operations managers, physicians, and staff to provide guidance on the utilization review process, inform them of regulatory and accreditation requirements, and draft accurate denial notices. Your excellent communication and writing skills will be essential in summarizing complex information and providing clear, concise reports.

Key Responsibilities:
  • Issue written denial notices that comply with all relevant laws, regulations, and contractual requirements.
  • Provide verbal notification on medically expedited referrals in accordance with regulatory agency requirements and department policy.
  • Convert complex contract language and clinical criteria into easily understood and member-friendly language.
  • Assess and respond to the needs of business partners to support a compliant notification.
  • Collaborate with others to solve business problems and escalate issues or risks as appropriate.
Requirements:
  • Minimum two years of experience disseminating complex information orally and in writing to customers/co-workers.
  • Minimum one year of experience in a position using medical terminology to review medical records, obtain or provide information, or take action.
  • Minimum two years of experience using computer systems and applications.
  • Thorough knowledge of medical terminology.
  • Basic knowledge of covered benefits and services.
  • Working knowledge of clinical services, policies, and procedures.
Preferred Qualifications:
  • Minimum two years of program experience; working knowledge of plan Service Agreements, operational structure/policies/procedures.
  • Minimum two years of experience working in an HMO or other healthcare environment in a direct service role like customer service, sales, marketing, etc.
  • Intermediate/competent knowledge of internal computer systems, including OA/KARE/CMS/OSCAR/Epic/Results Reporting/Lotus.
About Kaiser Permanente:

Kaiser Permanente is a leading healthcare organization dedicated to providing high-quality, patient-centered care. We are committed to improving the health of our members and the communities we serve.

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