Kaiser Permanente Senior Nurse Consultant in Oakland, California
HPRS is responsible for leading CA state regulatory initiatives across all functions statewide, as well as managing relationships & maintaining communications with stakeholders at all levels, both internally & externally. HPRS is responsible for: Assessment of organizational systems & processes to ensure appropriate Health Plan oversight & survey readiness & determine gaps for remediation prior to regulatory surveys. All regulatory filings related to Health Plan's Knox-Keene license (ex. contracts, benefits, delivery systems, new products). Benefits interpretation to ensure statewide consistency in providing benefits to members & compliance with benefits provisions in contracts. Processing regulatory complaints in a timely manner & trending, reporting, & analyzing data related to these complaints. May be responsible for project Mgmt relative to new regulations, legislation, surveys, new products, or other issues involving state regulators. Developing & directing proactive regulatory strategies to support membership growth. Provides/gathers clinical expertise for areas of compliance which involve medical necessity &/or quality concerns. Utilizes clinical expertise to conduct investigations & seek input from other clinical professionals as required. Acts as a liaison, problem-solver, & negotiator to achieve resolution on member requests & appeals. Responsible for reviewing & analyzing audit related reports & providing consultation on non-compliance.
Works directly w/Member Srvs organization & other clinical & admin leadership to investigate & facilitate resolution of complex & high profile member requests & appeals.
Provides/gathers clinical expertise for areas of compliance which involve medical necessity &/or quality concerns. Interprets clinical cases (grievances & appeals including lab values, medical records & interpretation) & presents appropriate clinical material for Physician review.
Reviews member complaints to identify potential quality issues that should be referred to the local Quality Depts.
Provides direct support & consultation on corrective actions developed by Depts for areas of non-compliance to ensure the compliance issue(s) is adequately addressed.
Utilizes clinical expertise to conduct investigations & seek input from other clinical professionals as required.
Acts as a liaison, problem-solver, & negotiator to achieve resolution on member requests & appeals. Leads &/or represents Regulatory Compliance at routine & ad hoc meetings on specific compliance areas relating to DMHC regulations.
Maintains database & provides all user groups timely notice of updates & implementation timeframes according to the regulations.
Works w/KFHP/KFH, Medical Group Depts & Sr Leadership at divisional, regional, & local levels as consultant on Dept of Managed Health Care (DMHC), Center of Medicare & Medicaid Srvs (CMS), Nat-l Committee for Quality Assurance (NCQA),& Dept of Health Srvs (DHS) compliance & develops, implements, tracks, & reports on work plans for correction.
Participates in the development & implementation of internal audits for DMHC, CMS, NCQA, DHS, & State Programs compliance.
Coordinates the audit process, including reviewing, analyzing, & reporting findings internally to the Dir, Sr Leadership, & to KFHP quality committees.
Assists in the development of appropriate policies relating to compliance. Participates in the development & implementation of necessary educational programs to ensure all appropriate parties are knowledgeable about their compliance responsibilities on an on-going basis.
This job description is not all encompassing.
- Minimum eight (8) years of experience and knowledge in subject matter area of expertise.
Graduate of accredited school of nursing required.
High School Diploma or General Education Development (GED) required.
License, Certification, Registration
- Current California RN license required.
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.
May require some travel to the Service Areas and/or Regional offices across the Division. Personal transportation required for local Service Area travel.
Expert knowledge of state regulatory requirements.
Must be able to work in a Labor/Management Partnership environment.
BSN or bachelor's degree in health related field preferred.
Master's degree preferred.
TITLE: Senior Nurse Consultant
LOCATION: Oakland, California
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.