Kaiser Permanente Coordinator Emergency Prosp Rvw Prg RN in Downey, California
To provide a centrally located and operated initiative for Kaiser Permanente (KP) Southern and Northern California Regions designed to help control emergency claims costs and maintain or improve quality of emergency care received by Health Plan members at non -Kaiser Permanente facilities nationwide. Will review for appropriateness situations, where a Health Plan member is receiving care in an emergency medical situations from community providers (in area and out of area). Will be using emergency medicine/critical care clinical experience and general guidelines, to determine whether to conditionally approve or deny care by community providers or whether to negotiate for lower level of care for the member or whether to refer to the SCPMG/TPMG MD on duty for review or whether to arrange transfer for medically stable members to a Kaiser Permanente Facility or Kaiser Permanente Contract Facilities.
Essential Responsibilities: - Prospective utilization review activities by reviewing cases with community emergency physicians and making decisions to conditionally approve or deny treatment and /or transfer Health Plan members with emergency needs. - Also direct and assist members appropriately requiring urgent care level of medical needs. - Encouraging limited patient work-up where practical to reduce out-of-plan expenditures and acting as a resource for the Claims Administration Department. - Arrange critical care transport of critically ill/hemodynamically stable Health Plan members from community facilities (in area and out of area) to Kaiser Permanente Facilities for the Southern and Northern California Divisions. - Assess available information and make quick appropriate/effective decisions regarding level of care required for Southern and Northern California Health Plan members. - Notification to Couc /Outside Utilization Coordinators (Southern California Division) /Case Managers (Northern California Division) regarding non plan admissions of Health Plan members for medical issues/situations. - Assist in the development and implementation of policies and procedures for the EPRP/Critical Care Transport Program. - Identify and report to the EPRP Quality Assurance Coordinator for submission to the Southern and Northern California Divisions KP facility QA/Risk Management Coordinators regarding quality and risk management issues to effect favorable management of members thereby increasing member satisfaction. - Document interactions and identify emergency medical claims to assure follow-through for the Claims Administration Department personnel for the Southern and Northern California Divisions. - Assist as a liaison with all three Kaiser Permanente entities, KP contract providers and external providers to help ensure that members with high cost claims receive timely, coordinated, high quality and cost effective care.
Qualifications: Basic Qualifications: Experience - Two (2) years of nursing experience in Emergency Care/Critical Care required. Education - N/A License, Certification, Registration - Current California RN license required.
Additional Requirements: - Knowledge of computers, ability to utilize various software as required. - Excellent written and verbal skills. - Demonstrated ability to communicate effectively in an understandable manner telephonically and in writing. - Demonstrated ability in planning, organizing, conflict resolution, negotiating and interpersonal skills. - Autonomous professional with minimal need for direct supervision.
Preferred Qualifications: - One (1) year Pediatric or Pediatric Critical Care experience or one (1) year Level III Neontatal Critical Care experience. - Bachelor's degree in nursing or healthcare related field preferred.
Notes: - May rotate to two additional assignments in ETAP and PTAC. Option II - Full Time: Six (6) twelve (12) hour shifts per pay period. - Three (3) shifts each week. - Employees will be scheduled every other weekend off. - The weekend for night shift for the purpose of this agreement will be Saturday and Sunday. -Full time employees scheduled forty (40) hours per week work 2,080 hours. If an employee is an option II for six (6) months he/she would earn 936 hours of credited service. - Employees on option II are to work an additional eight (8) eight (8) hour shifts or five (5) additional twelve (12) hours shifts and one (1) eight (8) hour shift during each six (6) months he/she remains on this schedule in an effort to ensure 2,000 hours per year. - If twelve (12) hour option chosen, shift will be 7:00 pm-7:30 am, back up 8 hour shift will be 8:00 pm to 4:30 am. - Every other weekend
COMPANY Kaiser PermanenteTITLE Coordinator Emergency Prosp Rvw Prg RNLOCATION Downey, CAREQNUMBER 624883
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.