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Kaiser Permanente

Integrated healthcare provider and payer platform

Quality/Utilization Management Coordinator

Medical, Clinical & VeterinaryPosted on Nov 14
Full-timePortland, OR, USANo salary listed

About the Job

Requirements

  • A minimum of one year of quality management or equivalent knowledge and experience is required.
  • A minimum of two years of community health, home health, or hospice nursing experience is required.
  • A minimum of two years as a registered nurse with experience in the care of the elderly is required.
  • A bachelor's degree or four years of experience in a directly related field is required.
  • A high school diploma or General Education Development (GED) is required.
  • A Washington registered nurse license or compact registered nurse license is required within six months of hire, and an Oregon registered nurse license is required within six months of hire.
  • A driver's license is required where applicable.
  • Basic Life Support certification is required.
  • Working knowledge of quality and utilization management, risk management, and infection control principles is required.
  • Thorough knowledge of Home Health Medicare certification, state licensure regulations, and The Joint Commission accreditation standards is required.
  • Basic knowledge of continuous quality improvement principles is required.
  • Computer and word-processing skills are required.
  • Written and verbal communication, analytical problem-solving, project management, and quantitative skills are required.
  • Experience working in a setting using Medicare Home Health Conditions of Participation is required.
  • Working knowledge of office machines, including PC-based computer systems using Windows, word processing, spreadsheet applications, and database applications is required.
  • Knowledge of Home Health Conditions of Participation and The Joint Commission standards is required.

Responsibilities

  • Analyze home health and home infusion referral requests to determine whether they meet established program criteria; interpret referral limitations and benefits, and communicate the information to members, non-plan providers, network providers, and internal staff as appropriate.
  • Receive information from contracted and non-contracted vendors about admissions of members; process referrals for contracted vendors in Portland, Salem, and Longview according to provider contracting agreements and health plan service agreements.
  • Communicate benefit information to home health and home infusion providers; enter and amend service authorizations in Tapestry as directed by the Home Health Manager or designee; maintain authorization binders and referral logs; provide additional data requested by vendors.
  • Implement the Quality Management program plan by collecting and analyzing quality and utilization data for outsourced patients.
  • Review plans of care and visits to ensure they are appropriate to care needs, and ensure benefits and services are standardized across the region.
  • Identify and assist with timely transitions across programs.
  • When programs are at capacity, process Portland, Salem, and Longview home health and home infusion referrals to outside vendors; assess vendor capacity, secure spot contracts as needed, authorize services, maintain referred-out statistics, and close authorizations at the end of care episodes with discharge dates and numbers of visits or days utilized.
  • Monitor the Home Health Notice of Non-coverage Line by removing messages, sending notices of non-coverage to patients or their powers of attorney for signature, and maintaining the notice log.
  • Assist in developing and continuously improving the Quality Management Program for Continuing Care Services through planning and evaluation activities; communicate ongoing quality and utilization-monitoring findings to appropriate individuals using written and verbal reports, charts, and graphics.
  • Attend interdisciplinary group meetings for outside agencies at the manager's request and develop working relationships with outside agencies, including annual site visits.

Desired Qualifications

  • At least three years as a public health nurse in a home health or hospice agency is preferred.
  • At least one year of supervisory experience is preferred.
  • At least one year of experience in discharge planning or utilization management is preferred.
  • Thorough knowledge of the Kaiser Permanente organization and structure, and medical terminology, is preferred.
  • Thorough knowledge of continuous quality improvement principles, tools, and practices is preferred.
  • Effective problem-solving, analytical, and organizational skills are preferred.
  • Working knowledge of Kaiser Permanente computer systems, including HealthConnect, common membership, and Tapestry, is preferred.
  • Working knowledge of Microsoft Excel is preferred.
  • Basic knowledge of provider relations and contractual agreements is preferred.
  • The ability to work independently with indirect supervision, assimilate technical information, and remain effective in a busy environment is preferred.
  • A master's degree in nursing, public health, business, or health care administration is preferred.

About the Company

Kaiser Permanente

Integrated healthcare provider and payer platform

Kaiser Permanente runs an integrated healthcare platform that lets members manage and pay medical, premium, and pharmacy bills online. It serves Medicare Advantage, Individual and Family, and non-employer plans, offering options to pay as a guest or set up payment plans. The platform works by presenting a centralized online portal where users can view bills, choose how to pay, and handle multiple types of charges in one place. Revenue comes from premiums and medical services fees, while the service aims to reduce administrative work for both providers and patients and encourage on-time payments. What sets Kaiser Permanente apart is its combination of healthcare services with a single billing experience across multiple plan types, focusing on a user-friendly, centralized payment process rather than handling billing through separate systems. Its goal is to provide a straightforward, reliable way for members to manage and pay their bills, improving convenience and payment timeliness.

Company size
10,001+
Company stage
Grant
Total funding
$7.5M
Headquarters
Oakland, CA
Founded
1945

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