Job Summary: Conducts reviews of medical records and treatment plans to evaluate and consult on necessity, appropriateness, and efficiency of health care services, under guidance. Communicates with physicians, managers, staff, members and/or caregivers regarding requirements related to medical necessity and benefit denials across the continuum of care, independently. Observes and identifies utilization trends and learns about addressing deficiencies in utilization review workflow/processes to ensure compliant and cost-effective care. Supports education and compliance initiatives by remaining up-to-date on the relevant regulations and guidelines, and participating in and providing feedback on education and training programs for staff and physicians to promote best practices in utilization management.
Essential Responsibilities:- Pursues effective relationships with others by sharing resources, information, and knowledge with coworkers and members. Listens to, addresses, and seeks performance feedback. Pursues self-development; acknowledges strengths and weaknesses based on career goals and takes appropriate development action to leverage / improve them. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work. Assesses and responds to the needs of others to support a business outcome.
- Completes work assignments by applying up-to-date knowledge in subject area to meet deadlines; follows procedures and policies, and applies data and resources to support projects or initiatives with limited guidance and/or sponsorship. Collaborates with others to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports the completion of priorities, deadlines, and expectations. Identifies and speaks up for ways to address improvement opportunities.
- Supports high-quality consultation by: communicating with physicians, managers, staff, members, and/or caregivers regarding requirements related to medical necessity and benefit denials across the continuum of care, independently; and leveraging working knowledge to ensure the correct and consistent application, interpretation, and utilization of member health care benefits, cost of care options, and coverage by members and physicians.
- Supports education and compliance initiatives by: remaining up-to-date and discussing with the team the relevant state and federal regulations, guidelines, criteria, and documentation requirements that affect utilization management; and participating and providing feedback on education and training programs for staff and physicians at the local level to promote best practices in utilization management.
- Assists in quality improvement efforts by: observing and identifying utilization patterns, trends, and opportunities for improvement; learning about utilization review workflows/processes including corrective action plans and standard work, and identifying deficiencies in workflows; and learning and actively adhering to utilization policies, procedures, and guidelines to ensure compliant and cost-effective care.
- Performs utilization reviews by: following standard policies and procedures when conducting reviews of medical records and treatment plans to evaluate the medical necessity, appropriateness, and efficiency of requested health care services, under guidance; and assessing the ongoing need for services, identifying potential issues/delays, and recommending appropriate actions for standard member cases.
Knowledge, Skills and Abilities: (Core)- Ambiguity/Uncertainty Management
- Attention to Detail
- Business Knowledge
- Communication
- Critical Thinking
- Cross-Group Collaboration
- Decision Making
- Dependability
- Diversity, Equity, and Inclusion Support
- Drives Results
- Facilitation Skills
- Health Care Industry
- Influencing Others
- Integrity
- Learning Agility
- Organizational Savvy
- Problem Solving
- Short- and Long-term Learning & Recall
- Teamwork
- Topic-Specific Communication
Knowledge, Skills and Abilities: (Functional)- Acts with Compassion
- Confidentiality
- Consulting
- Evidence-Based Medicine Principles
- Quality Assurance and Effectiveness
- Relationship Building
- Written Communication
Minimum Qualifications: - Bachelors degree in Health Care Administration, Business, Nursing, or directly related field OR minimum three (3) years of experience in medical benefits administration in a managed or health care setting or a directly related field.
Preferred Qualifications: Primary Location: Oregon,Portland,Kaiser Permanente Building
Scheduled Weekly Hours: 40
Shift: Day
Workdays: Mon, Tue, Wed, Thu, Fri
Working Hours Start: 08:00 AM
Working Hours End: 05:00 PM
Job Schedule: Full-time
Job Type: Standard
Employee Status: Regular
Worker Location: Flexible
Employee Group/Union Affiliation: NUE-NW-02|NUE|Non Union Employee
Job Level: Individual Contributor
Department: Kaiser Permanente Building - OSM SVC ADMIN-DME - 1008
Pay Range: $35.72 - $46.16 / hour Kaiser Permanente strives to offer a market competitive total rewards package and is committed to pay equity and transparency. The posted pay range is based on possible base salaries for the role and does not reflect the full value of our total rewards package. Actual base pay determined at offer will be based on labor market data, internal alignment, and a candidate's years of relevant work experience, education, certifications, skills, and geographic location.
Travel: No
