Description

Description:

Job Summary:

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.

Basic Qualifications:

Experience

• Two (2) years of nursing experience in Emergency Care/Critical Care required.

Education

• N/A

License, Certification, Registration

• Registered Nurse License (California)
  

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.
• Bachelors degree in nursing or healthcare related field preferred.

Notes:

• This is a temporary position for approximately 90 days

Primary Location: California,Downey,Downey Boeing - Independence Park
Scheduled Weekly Hours: 40
Shift: Night
Workdays: Sun, Mon, Tue, Wed, Thu, Fri, Sat
Working Hours Start: 07:00 PM
Working Hours End: 07:30 AM
Job Schedule: Full-time
Job Type: Standard Worker Location: Onsite
Employee Status: Temporary
Employee Group/Union Affiliation: B21|AFSCME|SCNSC
Job Level: Individual Contributor
Department: Independence Park - Emrgcy Pros Review Progm-EPRP - 0806
Pay Range: $60.79 - $74.4 / hour Travel: No On-site: Work location is on-site (KP designated office, medical office building or hospital). Worker location must align with Kaiser Permanente's Authorized States policy. Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.

For jobs where work will be performed in unincorporated LA County, the employer provides the following statement in accordance with the Los Angeles County Fair Chance Ordinance. Criminal history may have a direct, adverse, and negative relationship on the following job duties, potentially resulting in the withdrawal of the conditional offer of employment:

Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state, and local laws and regulations, accreditation, and licensure requirements (where applicable), and Kaiser Permanente's policies and procedures.

Models and reinforces ethical behavior in self and others in accordance with the Principles of Responsibility, adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty, shows consistency in words and actions; follows through on commitments.

Job duties with at least occasional or possible access to: (1) patients, the general public, or other employees; (2) confidential protected health information and other confidential KP information (including employee, proprietary, financial or trade secret information); (3) KP property and assets, for example, electronic assets, medical instruments, or devices; (4) controlled substances regulated by federal law or potentially subject to diversion.

Requisition #: 1397548

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