Kaiser Permanente Utilization Management Regulatory Coordinator in Aurora, Colorado
Assists in maintenance of regional utilization management (UM) activity regulated by federal, state, CMS and NCQA standards. Supports a culture of compliance, ethics and integrity. Maintains knowledge of policies and procedures and performs in accordance with the Principles of Responsibility and applicable regulatory requirements, external laws and accreditation standards. Reports appropriately observed fraud or abuse.
Acts as the regional resource for compliance with regulations and standards for UM activity. Acts as the internal resource and support for UM compliance related issues. Supports and assists to insure UM compliance in group and network delivery models; understanding and supporting that processes for compliance may differ. Works with various departments and their manager to support processes for UM decision making that meet regulatory requirements for both delivery models where appropriate. Provides education regarding relevant standards and requirements. Presents formal education activities for all departments involved in UM activity.
Assists with regional UM activities based on federal, state, CMS and NCQA standards. Reviews current and proposed federal, state, CMS and NCQA standards that regulate UM activity with the Colorado region; assists in determining their impact on health plan and medical group operations. Collaborates with all departments involved in UM activities, supports regulatory compliant processes and regional policies and procedures. Communicates compliance issues to UM Regulatory Officer along with recommendations for action and acts upon direction from the UM Regulatory Officer. Assists in compiling reports and results of internal audits to monitor compliance with UM standards: Audits of UM denial files, audits of inter-rater reliability and audits of any regulatory/accreditation bodies. Supports and assists in maintenance of regional UM denial system that tracks UM denials, standardized denial detail language and communication of updates and changes to users: Assists in the development and inputs template denial language that auto-populates denial letters. Based on regulatory requirements, assists with reviewing and amending denial letter templates as needed. Assists in the recommendation of modifications to the system as opportunities are identified to make the use of the system as clear and user-friendly as possible. Oversees the day to day activities of medical necessity denials generated by all departments using the Patient Denial Database insuring that appropriate rationale and denial language has been used. Assists to identify UM activity not currently monitored for compliance with regulatory requirements.
Provides management of the UM portion of regulatory audits including audits performed by Medicare, the State of Colorado, DOI, MDQR and NCQA. Assists in the UM component of regulatory agency audits, obtaining the required data, providing the relevant policies and procedures, collecting the documents required to substantiate compliance with the agencies standards.
- Minimum two (2) years of experience working in an area of utilization management or healthcare regulatory/compliance.
Bachelor's degree in health care management, nursing, or related field OR four (4) years of experience in a directly related field.
High School Diploma or General Education Development (GED) required.
License, Certification, Registration
Fluent in medical terminology and knowledgeable of clinical processes.
Excellent inter-personal relations and verbal communication skills required.
Organization, planning, analytical and writing skills required.
Must pass typing test with 55 wpm and less than 5% error rate.
Must pass MS Word test at intermediate level at 80%.
Must pass Business Writing test with proficient level of 2.51 or above.
Experience in utilization management, preferably in the managed care industry.
Knowledge of Federal, State, CMS and NCQA standards preferred.
TITLE: Utilization Management Regulatory Coordinator
LOCATION: Aurora, Colorado
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.