http://kpcareers.org/careers/quality-assurance,-utilization-review,-or-case-management-jobs en Essential Functions:
- Chairs & Co-chairs local committees focused on creating, implementing & monitoring work plans to achieve UM targets & performance improvement
- Shares accountability w/ other medical center leadership for the daily monitoring of utilization indicators & performance, identification & escalation of problems, & initiation & evaluation of action plans for achieving medical center targets & improve the quality of care & services
- Participates & provides UM expertise on local & regional committees, including UM Peer, UM Chiefs/Directors, Quality, TPMG, other departments & contracted/planned providers
- Manages projects related to chart reviews & conducts utilization data analysis (avoidable days, readmissions, UMAB, PRS reports, one-day stays, DRG's, LOS, PDR's, etc.) for trending & development of performance improvement initiatives
- Partners w/ the UM Chief & KFH/TPMG local medical center leadership, to engage the following areas in the development & implementation of a comprehensive utilization management, work plan to meet or exceed medical center targets
- Identifies & incorporates (as appropriate) evidence-based best/successful practices (e.g. care paths, innovative discharge planning/case management models, etc) into efforts to improve quality of care/service & reduce costs
- Collaborates w/ interdisciplinary teams across the continuum of care including, but not limited to (HBS, TPMG Sub-specialty departments, Nursing, MSW, PT/OT, HH, Hospice, SNF, CCM, Behavioral Health, Rehabilitation, etc.) to ensure patient care is effectively provided, clinically appropriate, service oriented, safe & cost effective
- Ensures compliance w/ regulatory/accreditation (NCQA, MDQR, CMS, Medical, DMHC, DOL, The Joint Commission, etc.) requirements related to UM by partnering w/ other departments & facilitating workgroups in maintaining survey readiness
- Directs staff review of the UM related aspects of treatment & discharge plans (Case Managers, Discharge Planners, Patient Care Coordinators, etc.) to ensure high quality & cost-effective discharge planning
- Supports UM staff in negotiating barriers or systems issues to expedite patient services during the hospital stay
- Accountable for oversight of UM activities (e.g., the appropriate use of InterQual, other criteria/guidelines), MIDAS, & the denial process
- May be responsible for claims management, repatriation, & ambulance
- May be responsible for oversight of coordination of care in planned & contract hospitals/providers
- Consultation & collaboration w/ TPMG/KFH Medical Center leadership to ensure discharge-planning activities are HR related activities
- Manages & resolves human resource, employee, department safety, & risk management issues
- Responsible for all aspects of staff management including, hiring, development/training, performance reviews, & terminations integrated into the broader service area utilization management initiatives
- Manages department budget & finances & develops, implements, & monitors departmental policies & procedures


Qualifications:

Basic Qualifications:
- A minimum ofthree (3)years of experience in management /leadership in a hospital or outpatient setting
- A minimum ofthree (3)years of experience in utilization management activities required
- BSN or BA in health care related field or equivalent experience required
- Graduate of accredited school of nursing
- Master's degree preferred
- Current California RN licensure
- Knowledge of the Nurse Practice Act, The Joint Commission, NCQA, & other local, state,& federal regulations
- Demonstrated skills in leading& facilitating the efforts of multidisciplinary groups
- Demonstrated strong communication, problem-solving& analytical skills]]> Wed, 16 May 2012 16:00:00 GMT 2437018-California-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Supervises the daily quality activities, ensuring timely & accurate data collection, and follow up of issues & quality of work
-Coaches staff & ensures their competency
- Coordinates & facilities staff support to various committees (e.g., quality, accreditation) which includes agenda preparation & monitoring of outstanding issues
- Provides reports based on timely & accurate data collection, identifies trends & monitors issues
- Develops implements & monitors quality department's policies & procedures; ensures they are in compliance w/ The Joint Commission, NCQA, CME, federal, state & local requirements
- Assists in developing & revising QA monitors to meet accreditation/regulatory standards
- Monitors the budgets, researches variances, & identifies opportunities to reduce costs
- Develops, implements, coordinates, & evaluates the CME programs, credentialing & privileges for permanent or temporary physicians & allied health providers
- Assists in preparation of educational materials & course objectives
- Maintains link between medical staff affairs & quality improvement, risk management, and continuing medical staff education
- Coordinates & prepares for CME, accreditation, licensing, & quality surveys/audits
- Maintains & monitors the various quality databases which may include quality reviews, CME, credentials & privileges, & provider profiles


Qualifications:

Basic Qualifications:
- Significant (typically 2-3 yrs) quality improvement or accreditation experience required
- Bachelor's degree or equivalent experience in a health care related field or business administration
- Previous supervisory experience recommended
- Ability to perform statistical analysis
- Current knowledge of The Joint Commission, NCQA, federal, state, & local requirements
- Knowledge & experience in application of adult learning theory in program development
- Must be able to work in a Labor/Management Partnership environment
]]> Wed, 16 May 2012 16:00:00 GMT 2436914-Walnut-Creek-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Provides leadership and expert consultation on the design, development, and implementation of programs related to the expertise area.
- Leads a group of consultants, analysts and/or staff focused on the delivery of service/products within the responsible technical area(s).
- Provides leadership and direction for the technical area(s) in accordance with the overall strategic direction of the group.
- Serves as the content expert of the responsible technical area(s) and provides technical assistance and advice.
- Develops standards, procedures, and policies to ensure that the responsible unit is maintained according to the acceptable level of quality from clients.
- Ensures that reports and information disseminated from the area(s) are accurate, timely and consistent, and that they satisfy the clients' needs.

Secondary Functions:
As a surveyor for the Medi-Cal Facility Site Review process, this position will participate fully in driving performance of the 200+ outpatient clinics throughout the Northern California Region. This position will participate in and possibly lead survey teams as in the review of primary care provider sites in accord with Medi-Cal requirements. This position will assist the Regional Master Trainer and Regional Site Review Trainer to develop and give training to RNs who become certified site reviewers and will train Service Area personnel on the requirements of the Medi-Cal Site Review process. This position will require some travel to Kaiser Permanente's provider sites throughout Northern California.

As part of the Accreditation team, the Clinical Practice Consultant position may participate in other aspects of the quality program to include Medi-Cal HEDIS chart abstraction and the NCQA accreditation process. Additionally, this position may support other related trend reporting, dashboard development, surveys, and audits as necessary.


Qualifications:

Basic Qualifications:
- Typically six or more years of experience in a management or clinical leadership role required.
- BSN or BA in health related field required; Master's degree preferred.
- Current California nursing license required.
- Demonstrated ability to determine the key business issues and develop appropriate action plans from multidisciplinary perspectives.
- Demonstrated subject matter expertise in health care operations and care delivery.
- Ability to adapt to constantly changing priorities and managing a wide range of projects.
- Demonstrated ability to lead professionals and manage others through influence and collaboration.
- Demonstrated ability to conduct and interpret quantitative/qualitative information with analytical problem solving and project management.
- Proven leadership skills in consulting.
- Must exhibit efficiency, collaboration, candor, openness, and results orientation.
- Must demonstrate an understanding of the operations of KP, health policy trends, and any applicable regulations related to the responsible technical area.
- Must be able to work in a Labor/Management Partnership environment.
]]> Wed, 16 May 2012 16:00:00 GMT 1637703-Oakland-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Manages the design, development, coordination, & quality of the credentialing process
- Creates operations & communications processes that support organizational strategies & business objectives
- Provides consulting services regarding regulatory, legal, accreditation program, & Regional credentialing standards throughout the region
- Manages the credential budget
- Manages credentialing function for TPMG Human Resources Department
- May coach, train, & direct work of credentialing staff
- Creates & manages credentials budget
- Works w/ practice site Credentials & Privileges Coordinators to share & implement best practices whenever feasible
- Interprets requirements & disseminates information to all involved parties to assure necessary compliance, compatibility, & continuous quality improvement of credentialing processes
- Informs Medical Group & KFH/P leadership of key issues & acts as Medical Group agent in influencing changes in program & agency requirements
- Partners w/ appropriate Program, Regional, CSA, Medical Group individuals & groups, accrediting bodies, & external consultants to develop & implement systems & processes that meet requirements & adhere to Regional Credentialing policies & procedures
- Collaborates w/ interregional peers to identify & implement best practices


Qualifications:

Basic Qualifications:
- Significant experience (usually 5+ years) in health care in an administrative or managerial position related to credentialing &/or accreditation
- Bachelor's degree in Health Care Administration, Public Health, or related field, or equivalent experience required
- Master's Degree preferred
- Certification as Certified Provider Credentialing Specialist (CPCS) preferred
- Extensive knowledge of the credentialing process, accreditation, & regulatory standards
- Significant knowledge of Federal & State regulatory requirements & accreditation standards e.g., The Joint Commission, TITLE 22, NCQA, NPDB, & certifying agencies
- Strong organization & communication skills & attention to details required
- Demonstrated problem-solving skills & initiative
- Proficient w/ Medical Terminology
- Ability to lead & facilitate processes through influence & collaboration
- Must be able to work in a Labor/Management Partnership environment
]]> Tue, 15 May 2012 16:00:00 GMT 2433491-Oakland-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Partners with clinical quality service lines to identify issues within operations for focus improvement efforts.
- In collaboration with the clinical lead, coordinates on-going, multiple projects (e.g., supporting the clinical service line model).
- Develops timelines and agenda items.
- Helps identify best methods and processes for performance improvement, including developing project plans, facilitating group process and training related to data collection/reporting.
- Support groups through the full rapid improvement cycle.
- Helps identify and recommend actions to correct activities and processes.
- Analyzes, interprets information and makes recommendations on data collection.
- Presents data in a graphical format to support leadership groups and committees strategic planning and decision-making.
- Analyzes and compiles data into spreadsheets and databases.
- Helps identify and communicate alternative solutions to projects as needed.
- Abstracts data using Health Connect; runs reports and communicates results of analysis effectively to key stakeholders.
- Maintains and coordinates audits.
- Assists with developing audit methods to assess performance improvement and to ensure regulatory compliance.
- Based on audit results, creates and presents reports using various systems and databases (e.g., MIDAS focus studies).
- Supports workgroups or committees (e.g., peer review).
- Prepares meeting materials, including agendas and minutes; coordinates conference room logistics; monitors and follows up with action plans).

Secondary Functions:
- Manages on-going multiple quality projects for the East Bay Risk department.
- Conducts needs assessment to plan projects, coordinates and monitors support services/staff, develops timelines, agenda items and presents findings.
- Analyzes, interprets information, and makes recommendations regarding The Joint Commission standards, CME requirements and credentialing/privileges.
- Designs and drafts proposal plans for sponsor approval.
- Monitors project costs, timelines, staffing, space and equipment needs.
- Recommends project strategy.
- Identifies best methods and processes; develops project planning, group process facilitation, training and appropriate information of technology.
- Serves as resource to the Risk and Patient Safety committees.
- Designs communication plans to implement recommendations.
- Identifies and recommends procedures to correct activities and processes.
- Develops and revises standards, policies, procedures and processes, such as improving the link between Quality Outcomes/ Improvement, Risk management, AR&L and Credentialing / Privileges.

Qualifications:

Basic Qualifications:
- Demonstrated ability in managing databases, developing reports and data analysis using Excel and Access (3-5 years).
- Bachelor's degree in business administration, information technology or health care related field OR equivalent experience.
- Demonstrated knowledge of quality improvement; accreditation and licensing.
- Strong problem solving, project management and teamwork skills.
- Advanced skills with Microsoft applications (Word, Excel, Access and Power Point).
- Must be able to work in a Labor-Management partnership.

Preferred Qualifications:
- Significant experience (typically 3-5 years) in health care facility.
- Supervisory experience preferred.
- Current knowledge of The Joint Commission, Title 22 and NCQA required.
- Demonstrated knowledge of adult learning theories.
- Must be PC literate, Microsoft Office applications preferred.
- Valid CA driver's license and personal means of transportation preferred.]]> Tue, 15 May 2012 16:00:00 GMT 2433448-Oakland-Quality-Assurance,-Utilization-Review,-or-Case-Management
Essential Functions:
- Conducts utilization review for in-house patients and/or members who have been admitted to contracted facilities.
- Conducts clinical reviews based on established treatment criteria.
- Reviews utilization patterns and identifies trends and problems areas for special studies.
- Assists other health care providers in the discharge planning process and triaging on alternative unit of care.
- Assists in collecting and assimilating clinical data to enhance the quality of services.
- Generates quality improvement results.
- Collaborates with physicians on clinical reviews, keeps them appraised of Kaiser clinical criteria.
- Reports and investigates unusual occurrences and questions inappropriate decisions based on their professional expertise.
- Interviews patients/caregivers regarding care after hospitalization.
- Counsels on Medicare and health care plan coverage.
- Coordinates referrals to appropriate agencies/facilities.

Secondary Functions:
- Conducts clinical reviews based on established treatment criteria for members admitted to contracted facilities.
- Collaborates with physicians on plans for clinical reviews, keeps them appraised of Kaiser clinical criteria.

Qualifications:

Basic Qualifications:
- Previous experience in an inpatient setting (usually two (2) years).
- Previous experience utilization experience required (usually one (1) year).
- Bachelors degree, or equivalent experience, in nursing or a health related field required.
- Master's degree preferred.
- Graduate of accredited school of nursing.
- Current California RN license.
- Clinical expert in area of review preferred.
- Demonstrated knowledge of diagnostic codes.

Preferred Qualifications:
- Education: Fifteen (15) C.E. credits (CEU) in area of clinical specialty in past 12 months.
- Current BLS provider status.
- Experience in utilization or DC planning highly desirable.]]> Mon, 14 May 2012 16:00:00 GMT 2429289-San-Francisco-Quality-Assurance,-Utilization-Review,-or-Case-Management
Essential Functions:
- Ensures that a highly effective Risk Management & Patient Safety Education Program is developed, implemented & sustained.
- Authors annual risk management & patient safety (Safe Care) plan that links program goals w/ (1) organizational vision & mission statements & strategic priorities set by the governing body (2) previous year's accomplishments (3) results of ongoing monitoring & evaluations & (4) licensing & accreditation requirements.
- Develops & maintains highly effective relationships w/ key stakeholders & departments such as leadership team members, professional staff & its leadership, quality management/performance improvement department, continuing professional staff education, patient care services, pharmacy, infection control, environmental health & safety, employee assistance program staff, healthcare ombudsman & mediator, local & regional medical legal, member services as well as external regulatory & accrediting bodies.
- Partners w/ Assistant Physician-in-Chief for Risk to ensure program goals & objectives are operationalized across the continuum.
- Co-chairs the Medical Center's Risk Management/Patient Safety focused committees fulfilling the organizational obligations for committee management & reporting structure.
- Responsible for the Management of Risk Data & Information: Develops & fosters internal risk identification mechanisms including, but not limited to, incident reports, staff referrals, medical records reviews, review of patient complaints, reviewing pertinent quality improvement information, closed claims analysis & environmental risk/safety assessments.
- Communicates pertinent risk management information through regular & ad hoc analysis reports regarding trends, patterns, & issues to the KFH/HP Board of Directors, Leaders, TPMG leadership, Executive Committee, other committees/groups as appropriate.
- Recommends patient safety/error reduction initiatives to leadership.
- Facilitates the design of error reduction projects & maintains oversight to ensure projects stay on track.
- Ensures root cause analyses are conducted timely & meet the test of being thorough & credible.
- Ensures high-risk processes are identified for Failure Modes & Effects Analysis (FMEA).
- Responds to emerging needs of the organization relating to new legislation & standards by drafting policies & procedures &/or assisting departments w/ revisions of current procedures.
- Provides risk management expertise to physicians & staff when faced w/ patient care dilemmas.
- Represents the organization during patient/family conference, as appropriate & required.
- Coordinates w/ Medical-Legal Affairs to investigate or assist w/ claims investigation, as appropriate.
- Represents the Medical Center on regional committees as requested & appointed.
- Represents Kaiser Permanente to outside organizations & regulatory & accrediting bodies, as requested & appropriate.
- Manages staff & makes recommendations regarding the need for staff, space & other resources.
- Manages & resolves human resources & labor relations specific to the Risk Management & Patient Safety Department.
- Assume other duties as directed.

Secondary Functions:
- Programs will be directed at the identification, analysis, and implementation of initiatives to improve systems of healthcare while reducing human error within the system.
- Also responsible for ensuring appropriate actions are taken when heatlhcare errors have occurred and caused harm to members, patients, staff and/or the organization.
- Consults with providers and staff regarding specific patient care dilemmas.
- Builds and sustains strong, effective relationships with KFH/HP and TPMG leaders/managers/staff.
- Ensures collaboration with local and regional Medical Legal Departments.
- Participates in CME and CEU program through the provision of programs on such topics as loss prevention, informed consent process, confidentiality, communcation of unanticipated outcomes, and human factors.

Qualifications:

Basic Qualifications:
- Substantial experience (usually seven (7) plus years) in risk management/patient safety or performance improvement in an integrated healthcare delivery system.
- Bachelor's degree required; strongly preferred to be in nursing of other clinical healthcare field.
- Advanced degree in law, healthcare risk management, healthcare business or business administration strongly preferred.
- Demonstrated knowledge of risk management principles.
- Demonstrated knowledge & understanding of legal principles of tort w/ ability to apply in any situation.
- Ability to apply federal/state healthcare laws & accreditation standards to all settings of care.
- Proven basic statistical analysis & problem-solving skills.
- Persuasive oral & written skills.
- Strong interpersonal skills w/ proven ability to influence across functional lines.
- Success in curriculum development & presentations to large groups of diverse healthcare providers.
- User knowledge of various software applications.
- Must be able to work in a Labor/Management Partnership environment.]]> Fri, 11 May 2012 16:00:00 GMT 2424157-North-Bay-Quality-Assurance,-Utilization-Review,-or-Case-Management
Essential Functions:
- Responsible for reviewing, processing, and auditing claims for payment and appropriateness of charges and pursues adjustments as warranted.
- Screens, audits, and processes claims of specific criteria for appropriate payment.
- Establishes effective ongoing relationships with community hospitals and providers.
- Participates in educational, provider relations, and contracting meetings with providers to address medical claims payment issues.
- Interface with providers as necessary to compare billed charges to the medical record.
- Provides support to the Claims Administration Department in determining financial liability for out-of-plan medical services.
- Performs special projects, reconciliations, research, and analysis relating to the utilization and cost of medical services.
- Works closely with various departments to coordinate the flow of information involving payment of medical bills and analyses of financial liability.
- Ensures compliance with contractual obligations on claims payments; documents findings and writes follow-up reports; recommends and implements innovative strategies to retain members, contain medical costs, and improve efficiency.
- Serve as expert resource to staff in areas of clinical claims review.
- Provide ongoing educational development and professional competency training for payment of medical bills and analyses of financial liability.
- Provide ongoing and frequent clinical oversight to establish close working knowledge of individual staff strengths and work with individual staff to identify and develop areas of growth opportunities document staff competencies annually.
- Maintain organizational, community, and professional vigilance and involvement in appropriate task forces and committees.
- Develop and maintain subject expertise and interdepartmental relations to optimize communication and working relationships, and to position the clinical claims review resources to effectively support organizational goals.
- Support development of creative, visionary potentials for program improvements.
- Actively engage and support administrative efforts to develop sound programs and strategies to effectively manage 'right care in the right setting at the right cost', with focus on optimal utilization and cost of acute and continuing care resources.
- Perform other duties as requested.


Qualifications:

Basic Qualifications:
- Minimum of 5 years work experience in medical necessity review.
- BSN degree.
- Expert level abilities in inter and intra departmental communication, organization, planning, and implementation of successful programs.
- Demonstrated ability to work effectively with others.

Preferred Qualifications:
- Minimum of 5 years of experience in utilization review or a managed care setting.
- Licensure as a Registered Nurse.

Salary Range:
$87,800 - $114,000]]> Wed, 09 May 2012 16:00:00 GMT 2444010-Portland-Quality-Assurance,-Utilization-Review,-or-Case-Management
Essential Functions:
- Assures support systems that allow compliance w/ regulatory CME requirements & legal mandates
- Assists in the development & implementation of services provided for all physician education activities
- Provides support to the DME & CME chairs committee in carrying out the functions of the program
- Collects & compiles data & QA information for the preparation of educational activities, site visits, & annual reports
- Maintains program documentation/records
- Consults w/ physicians & others to interpret & observe the guidelines set by CMA when providing CME programs
- Monitors department CME budgets to ensure timely payment of invoices, log-ins of all CME expenses, & helps ensure expenditures remain within budget

Secondary Functions:
- Provide support to GME program for vacation, PTO relief

Qualifications:

Basic Qualifications:
- Experience in desktop publishing, spreadsheet, database, email & internet
- Preliminary data analysis experience
- Two (2) years experience in an acute care setting working w/ regulatory agencies or legal entities & preparing for site/compliance visits preferred
- Bachelor's degree or equivalent related experience (four (4) years preferred)
- Demonstrated ability to manage projects in a health care setting
- Demonstrated knowledge of CMA, AMA & related regulatory requirements & copy right laws
- Demonstrated ability to delegate word, be effective in written & oral communication, consultative & interpersonal skills
- Familiarity w/ audio-visual equipment utilization
- Must be able to work in a Labor/Management Partnership environment

Preferred Qualifications:
- Previous experience in CME and GME functions]]> Wed, 09 May 2012 16:00:00 GMT 2418084-Walnut-Creek-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Determines & manages appropriate levels of care & services; using clinical knowledge, established guidelines, & physician consultation
- Implements changes in contract benefits, state & federal regulations, & established review criteria guidelines
- Synthesizes & analyzes a large volume of data related to the member, benefits, eligibility, facilities, contracts, & clinical status to identify issues & facilitate problem solving that results in continuity of care, quality of care & optimal resource management for the patient
- Coordinates care w/ various internal & external customers to facilitate high quality, timely, & cost effective care & service
- Consults & educates other staff, physicians, departments & members regarding resource management options that provide high quality while efficiently using available resources
- In addition to defined technical requirements, accountable for consistently demonstrating service behaviors & principles defined by the KP Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives
- Also accountable for consistently demonstrating the knowledge, skills, abilities, & behaviors necessary to provide superior & culturally sensitive service to each other, to our members, & to purchasers, contracted providers & vendors


Qualifications:

Basic Qualifications:
- A minimum of 3 years of clinical experience in hospital setting, preferably ICU, CCU, Med-Surg
- Experience in utilization review, case management, discharge planning, & managed care
- Knowledge & experience w/ Medicare coverage guidelines & medical criteria such as Interqual or Milliman & Robertson
- Current unrestricted license as a RN in the State of Colorado
- Knowledge of quality & utilization review methods, statistical techniques, utilization management compliance standards, & regulatory elements
- Effective interpersonal, communication, & negotiating skills
Preferred Qualifications:
- Prefer clinical experience in hospital setting to be in ICU, CCU, Med-Surg

Rotate schedule. Works holidays, nights and weekends. Floats between departments/facilities/locations.
Main location is Exempla Good Samaritan Hospital and will float to all core and non-core hospitals

Salary Range: $31.84- $37.46 Hourly
]]> Tue, 08 May 2012 16:00:00 GMT 2415050-Denver-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Plans, develops, assesses & evaluates care provided to members.
- Collaborates w/ physicians, other members of the multidisciplinary health care team & patient/family in the development, implementation & documentation of appropriate, individualized plans of care to ensure continuity, quality & appropriate resource use.
- Assesses high risk patients in need of post-hospital care planning.
- Develops & coordinates the implementation of a discharge plan to meet patient's identified needs; communicates the plan to physicians, patient, family/caregivers, staff & appropriate community agencies.
- Reviews, monitors, evaluates & coordinates the patient's hospital stay to assure that all appropriate & essential svcs are delivered timely & efficiently.
- Participates in the Bed Huddles & carries out recommendations congruent w/ the patient's needs.
- Coordinates the interdisciplinary approach to providing continuity of care, including utilization mgmt, transfer coordination, discharge planning, & obtaining all authorizations/approvals as needed for outside svcs for patients/ families.
- Conducts daily clinical reviews for utilization/quality mgmt activities based on guidelines/standards for patients in a variety of settings, including outpt, ER, inpt & non-KFH facilities.
- Acts as a liaison between inpt facility & referral facilities/agencies & provides case mgmt to patients referred.
- Refers patients to community resources to meet post-hospital needs.
- Coordinates transfer of patients to appropriate facilities; maintains & provides required documentation.
- Adheres to internal & external regulatory & accreditation requirements & compliance guidelines including but not limited to: JCAHO, DHS, HCFA, CMS, DMHC, NCQA & DOL.
- Educates members of the healthcare team concerning their roles & responsibilities in the discharge planning process & appropriate use of resources.
- Provides patients w/ education to assist w/ their discharge & help them cope w/ psychological problems related to acute & chronic illness.
- Reviews, analyses & identifies utilization patterns & trends, problems or inappropriate utilization of resources & participates in the collection & analysis of data for special studies, projects, planning, or for routine utilization monitoring activities.

Qualifications:

Basic Qualifications:
- Minimum two (2)years clinical experience as an RN in an acute care setting required.
- Bachelor's degree in nursing or healthcare related field preferred or current equivalent related work experience.
- Graduate of an accredited school of nursing required.
- Current and valid California RN license required.
- Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques and methods of utilization review/management, discharge planning and case management.
- Working knowledge of regulatory requirements and accreditation standards (JCAHO, Medicare, Medi-Cal, etc.).
- Demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking and problem-solving skills.]]> Mon, 07 May 2012 16:00:00 GMT 2415061-California-Quality-Assurance,-Utilization-Review,-or-Case-Management Kaiser Permanente
Oakland, CA

The Meaningful Use Programming Consultant supports Meaningful Use report specifications, code and documentation that support KP's MU qualification. Develops relationships with business, IT, clinical partners. Develops, recommends changes, and maintains business processes and documentation. Provides project management support for reporting.

The Meaningful Use Project Management Office (MU PMO), which the Meaningful Use Programming Consultant would be a part of, is responsible for managing and driving successful execution of Kaiser Permanente's Meaningful Use national program. The PMO is responsible for the development and execution of business and IT plans to qualify Kaiser Permanente's regions as meeting MU criteria as established by the Centers for Medicare & Medicare Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC)- http://www.cms.gov/EHRIncentivePrograms/35_MeaningfulUse.asp#TopOfPage < http://www.cms.gov/EHRIncentivePrograms/35_MeaningfulUse.asp#TopOfPage >.

Essential Functions:
- Works on assignments of moderate scope.
- Works within accepted guidelines.
- Requires moderate planning and scheduling.
- Works with the team to initiate, coordinate, and facilitate reporting and analytical projects to meet client needs and achieve programmatic and organizational objectives.
- Coordinates project by effectively communicate project assumptions, methods, and results to clients and other interested parties. Elicits and incorporates feedback from clients to inform the design of reports and enhance their effectiveness.
- Begins to establish and maintain effective working relationships both internal and external to the CSPC.
- Facilitates or heavily participates in multiple inter-regional reporting workgroups
- Applies analytic knowledge, skills and experience to develop, modify, test and implement reports and report templates.
- Reviews enhancement requests and release notes for Clarity data, and reports impacts. Keeps up to date on new views, reporting workbench templates, data marts, and other reporting utilities/infrastructure.


Qualifications:


Basic Qualifications:
- A minimum of 4 years of related work experience (i.e., in a reporting or analytical environment, preferably in healthcare).
- Demonstrated effectiveness in written and verbal communication of technical material.
- With some supervision, demonstrated ability to design, develop, manage, and coordinate reporting and analytical efforts among multiple constituents.
- Project management skills, including setting priorities, developing work plans, and meeting deadlines.
- A minimum of 2 years of experience with RDBS and RDBS structures, SQL data manipulation and interpretation of large databases required.
- A minimum of 2 years of statistical or report programming in R, SAS, SQL, Crystal, Business Objects or Cognos.
- Excellent in critical thinking; excellent analytical and problem-solving skills.
- Ability to work within a core team and among cross-functional teams.
- Outstanding written and verbal communication and effective interpersonal skills.
- Must be able to work with minimal supervision. - Knowledge of healthcare industry, especially healthcare analytics a plus.
- A minimum of 4 years of experience in computer science, engineering, related technical field or a 4 year degree of equivalent experience.

Preferred Qualifications:
- Master's degree preferred.
- Oracle, UDB, Teradata experience a plus.
-VBA or VBS programming a plus
-Epic Chronicles and Clarity training a plus.
- Experience with data warehousing a plus.
- Project management experience and working matrix management structures a plus]]> Sun, 06 May 2012 16:00:00 GMT 2408343-Oakland-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Conducts concurrent & retrospective clinical studies by performing review using screening criteria as prescribed by the medical staff
- Performs variance screening & tracking by reviewing Clinical Pathway documentation to monitor quality of care issues
- Aggregates data & refers all cases not meeting established criteria to Departmental Quality Assurance
- Enters QA/RM/UM variances from care paths, screening indicators, utilization focused studies, Medicare admission necessity, & continued stay reviews into the department computer database
- Prepares statistical reports based on information retrieved from MIDAS, EZ-QA, PARRS, &/or CABS/ADT systems & manual record review & data aggregation
- Enters unusual occurrence & other information into the department database
- Creates & runs reports for departments & the Committees
- Prepares worksheets, distributes charts, completes applicable portions of the physician peer review forms, & monitors their completion by the medical staff
- Maintains confidentiality of all data
- Organizes & maintains data to assure integrity & reliability for future reporting


Qualifications:

Basic Qualifications:
- Recent experience as a quality analyst, or similar position in health care preferred
- High school diploma & computer experience
- Some college level courses preferred
- Working knowledge of medical terminology preferred
- Skills in medical record reading & review preferred. (Higher education substituted for experience)
- Must be able to work in a Labor/Management Partnership environment
]]> Tue, 01 May 2012 16:00:00 GMT 2399524-Walnut-Creek-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Directs, plans & evaluates all professional & technical aspects of the region's health information management systems providing broad & appropriate communication & feedback to medical center HIM departments. Acts as a change agent to ensure the HIM departments in the centers are able to identify & meet the outcome expectations of their customers.
- Direct supervision of the Area HIM Managers in the daily operations of the center HIMS functions, including document imaging, forms completion & release of information in addition to other aspects of managing patient health information.
- Formulates & implements strategies, policies, systems & procedures for center Health Information Management Services in the region & ensures compliance w/ legal, regulatory & accreditation agency requirements.
- Direct supervision of the Transcription supervisor in the daily operations of the transcription services.
- Represents the RHIMS department on appropriate regional task forces, such as the Confidentiality committee & Risk Management efforts, to ensure that medical records meet all legal & regulatory.
- Acts as a liaison between KPMAS & outside entities (i.e., hospitals) regarding patient health information systems, policies & procedures.
- Participates in the development & implementation of automated systems including KP HealthConnect, providing medical information to KPMAS staff & providers. Communicates & coordinates medical information activities w/ the Information Systems department & provides input regarding the operational impact of automation.
- Develops & maintains medical information systems that provide the capacity for appropriately responding to requests for release of information. Establishes & manages the relationship w/ outside copy service to include developing & issuing requests for proposals & contract management & issue resolution of disputes. Maintains accountability for cost control & revenue recovery.
- Keeps current w/ regulatory & accreditation requirements & ensures medical information systems & operations compliance. Provides interpretation of & disseminates information on changes in requirements in a timely manner.
- Works in concert w/ Legal Services & Government Relations regarding legislative & regulatory matters. Provides input regarding the relevance & impact on proposed legislation to KPMAS.
- Remains current on issues related to confidentiality & security of medical information systems & the specific information contained therein. Ensures the confidentiality of information whether it is contained in hard copy, film, disk, scanned, or other media.
- Coordinates & directs the development, support & maintenance of Quality Assurance activities involving health information management. Provides expertise & support for QA activities of other departments interfacing w/ medical information systems.
- For full job description see kp.org/jobs.


Qualifications:

Basic Qualifications:
- 7 years of progressive health information management experience in an electronic & paper environment required.
- 5 years of supervision/management of health care personnel required.
- Clinical experience & knowledge of medical terminology required.
- Bachelor's degree required, preferably in Health care Information Administration, MPH, Health Administration, Health Informatics or a Health Care related field required.
- Knowledge & experience in information privacy laws, access, release of information & release control technologies required.
- Knowledge of regulatory & accreditation requirements for medical information required.
Preferred Qualifications:
- Master's degree in a related field strongly preferred.
]]> Tue, 01 May 2012 16:00:00 GMT 2399472-Washington-DC-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Serves as a consultant in all areas of quality assessment, improvement, demonstration, & utilization management to regional staff & medical center physicians & staff
- Leads & develops work teams or participates as a member of a quality/utilization work team
- Projects will range from developing internal quality programs to responding to internal or external regulatory requirements
- Regulatory requirements may include a review by a state or national organization
- Selects & uses appropriate data & information from DOQU as it applies to each individual project
- Oversees the following components of studies: definition of population, sample selection, data collection, chart review, data analysis, & statistical adjustment
- Prepares Kaiser as a whole for specific regulatory reviews or audits
- This also applies to special projects requiring collaboration w/ the other entities
- Insures that the study plans have identified & adequately addressed the potential pitfalls that may be caused by data problems
- Educates physicians & staff regarding regional projects or regulatory reviews (i.e., the interpretation of regulatory requirements & the methods of compliance when preparing for a review or the interpretation of project goals)
- Reviews the work of quality & utilization analysts for purposes of quality control

Qualifications:

Basic Qualifications:
- Previous clinical experience in nursing, rehabilitation therapy, social services or other discipline which conducts program/treatment outcomes evaluation
- Usually three (3) - five (5) years of relevant previous experience in quality/utilization management and/or accreditation
- Usually one (1) - three (3) years of experience providing consultative services, analytical studies and project management experience which may be included in the aforementioned experiential requirement
- Bachelor's degree in nursing or related healthcare field such as management, public health, health services/business administration OR four (4) years (usually)of equivalent relevant experience in quality/ utilization management
- Current California RN License preferred
- Ability to demonstrate knowledge of and apply/utilize quality improvement, quality control techniques, analytical skills, communication skills, JCAHO, Title 22, NCQA, MediCal, and HCFA standards and project management skills
- Ability to demonstrate proficiency with word processing and use of spreadsheets]]> Mon, 30 Apr 2012 16:00:00 GMT 2391560-Los-Angeles-Quality-Assurance,-Utilization-Review,-or-Case-Management Medical Audit Coordinator
Oakland, CA

The Medical Audit Coordinator reviews claims for services obtained outside of Kaiser facilities for compliance with health plan service agreement with members; identifies health plan claims with potential quality of care issues, continuity of care problems, or access issues at medical facilities; and audits hospital billings on site at non Plan provider facilities and negotiates successful resolution of claim.

Essential Functions:
- Provides clinical expertise to other departments such as Workers Comp., TPMG referrals, CSA/ MSA outside case management in areas related to hospital and physician billing practices and cost containment activities.
- Works with legal department when indicated to resolve payment disputes.
- The Medical Audit Coordinator serves as a consultant to CSA Continuing Care teams and case managers on issues of non-Plan pricing, billing problems, procedures and benefit compliance issues. Identifies opportunities for cost containment. Works with regulatory compliance for review of benefit.
- Responsible for review of ICD-9, CPT codes, medical records, UB- 92 and HCFA forms as well as Kaiser Permanente internal systems (OTRS, Advice call logs). Determines if bills are payable or if additional information is needed.
- Works with PRS staff as a resource for decision-making and medical terminology.
- Plans, organizes daily work to meet compliance timeframe's. Provides feedback to manager to ensure work is within compliance.
- 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.
- Decisions are made following State and Federal regulations related to provider reimbursement for claims, NCQA standards, Kaiser internal policies related to payment of out of Plan services.
- Determines whether to pay claim or refer to an advisor based on clinical criteria related to emergency medical condition.
- Payable claims are analyzed for correct contract interpretation, Medicare fee schedule interpretation, correct coding.
- Analyzes information from multiple internal and external sources when reviewing a claim episode of care.
- Assigns work based on regulatory compliance, staffing, staff skill level and competing priorities
- The Medical Audit Coordinator serves as a consultant to CSA Continuing Care teams and case managers on issues of non-Plan pricing, billing problems, procedures and benefit compliance issues.
- Works with interregional counterparts for matters of billing resolutions and clinical issues and with regulatory department regarding issues of compliance and interdepartmental review of benefit issues
- Independently prioritizes work on hand based on compliance.
- Expected that this position possess the ability to work with minimal direction from supervisor.
- Has the authority to direct the work of others such as Project Analyst, to meet compliance dates.


Qualifications:

Basic Qualifications
- Graduate of an accredited Nursing Program.
- Current California RN license is required.
- 5+ years clinical experience, preferably in critical care.
- Ability to make timely and sound decisions, and act independently and negotiate successful resolution in difficult situations.
- Proficient in the use of MS Applications (Excel, Access, Power Point), excellent ability with proprietary, mainframe processing systems and KP Technologies
- Demonstrates understanding of medical terminology, ICD-9 coding, CPT coding principles
- Knowledge of LMP required.
- Strong customer service skills
- Must understand DHS, Medicare, ERISA guidelines for payment of claims
- Knowledge of state regulations pertaining to member and provider appeals rights required
Qualified candidates must have the following skills:
- Takes Accountability
- Communicates Effectively
- Focuses on the Customer
- Collaborates
- Drives for Results
- Business Acumen
- Makes Effective Decisions
- Solves Problems through Planning & Analysis
- Pays Attention to Detail
]]> Tue, 24 Apr 2012 16:00:00 GMT 2377204-Oakland-Quality-Assurance,-Utilization-Review,-or-Case-Management
Essential Functions:
- Works independently with minimal supervision on KPHC medical record review to support regulatory reporting across the region.
- Evaluates regional clinical documentation and records clinical data from KPHC based on strict abstraction guidelines.
- Exercises independent judgment to derive appropriate interpretation of the Joint Commission core measures specifications in order to accurately represent KP care processes in the data.
- Maintains open communication with teammates and local medical center staff regarding findings and learnings.
- Makes key decisions regarding appropriate data collection methodology that are based on established specifications and protocols.
- Recommends solutions towards improvement opportunities.
- Leads and provides technical leadership to projects.
- Sets strategic direction of projects.
- Develops project plans which identify key issues, problems, approaches, performance metrics and resources required.
- Designs processes to address identified problems. Establishes team membership and negotiates time commitments and resource allocation.
- Communicate and collaborate with key regional stakeholders and facility multi disciplinary teams and providers on abstraction findings and problem solving for areas not performing at target.
- Actively participates or may lead in analyzing data and developing recommendations and action plans.
- Accountable for the development of project documentation for senior executives and other key clients to facilitate sharing of project outcomes and best practices.
- Plans and facilitates meetings.
- Makes formal presentations to various senior level audiences.
- Provides staff leadership to multi-disciplinary teams.
- Motivates team members and facilitates team meetings.
- Acts as liaison, problem solver, and facilitator.
- Cultivates and reinforces appropriate group values, norms, and behaviors.
- Provides guidance to team on performance and productivity issues.
- Assesses project impact on the workforce. May include developing training program for different levels of audiences.

Qualifications:

Basic Qualifications:
- Three (3) plus years of experience in specified technical area.
- Project management experience in health care preferred.
- Experience in conducting research, critically evaluate data, and recommend solutions preferred.
- Bachelors degree or equivalent experience in Business Administration, Health Care Administration, Operations Research, Public Health Administration, or other related field.
- Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) preferred.
- Ability to determine key business issues and develop appropriate action plans from multi-disciplinary perspectives.
- Demonstrated ability to conduct and interpret quantitative and qualitative analyses.
- Good project management and consulting skills.
- Excellent verbal and written communication skills.
- Consistently demonstrate the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to customers, contracted providers, and vendors.
- Familiarity with Medical Record terminology preferred.
- Strong background in abstracting data and ability to recognize disease-specific workflows preferred.
- Ability to work independently and interact with various levels of staff at the medical centers preferred.
- Ability to adhere to project protocol and timelines preferred.
- Able to handle charged issues and experience in conflict resolution preferred.
- Knowledge of Microsoft Word, Excel, Access, and Powerpoint preferred.
- Must be able to work in a Labor/Management Partnership environment.]]> Tue, 24 Apr 2012 16:00:00 GMT 2377196-Walnut-Creek-Quality-Assurance,-Utilization-Review,-or-Case-Management Kaiser Permanente
Oakland, CA

The Care Management Institute (CMI) supports Kaiser Permanente in setting priorities for population care and transforming its health care culture. CMI partners with clinical and operational experts, leaders and members in all eight KP regions to serve as a gathering point for best practices, coordinated learning, and the development of new clinical care models. CMI is seeking a Senior Consultant who supports analytic projects primarily focused on key CMI initiatives aimed at assisting the organization in making strategic data-related decisions by analyzing, manipulating, tracking, internally managing, and reporting data. The Senior Consultant will lead analytic projects both as an analyst and as a high-level consultant. The person will be responsible for successfully managing projects and execution of goals as well as the communication and translation of insights into action to catalyze improvement and change across Kaiser Permanente's health care delivery systems.

Essential Functions:
- Analyzes, summarizes, and validates data provided by programmer
- Works in collaboration with programmer to produce clinical performance metrics and analyses on agreed-upon timelines
- Works closely with clinical and operational subject matter experts to understand what metrics and analyses would best support performance improvement. Translate needs, issues, and ideas into effective strategies and action plans, developing creative solutions as needed.
- Works closely with other analytic departments to produce performance metrics and analyses
- Develops process and work plan for production of reports/dashboards or analyses
- Compiles and reports Regional performance data
- Clarifies Regional reporting expectations and commitments
- Develops interregional consensus on new measures
- Supports Regions in developing and reporting new metric
- Develops specifications for new metrics including validating new metrics and operationalizing metrics and analyses (includes pilot and/or other metrics) in collaboration with clinical and operational subject matter experts
- Deliver metrics and analytic results using custom reports or automated reporting tools. Interpret results and communicate to subject matter experts and to leaders
- Guide use of metrics and analyses towards actionable results
- Collaborate effectively with other analytics staff

Preferred Qualifications:
- Excellent teaching/mentoring skills
- Strong problem solving ability
- Ability to multi-task and set priorities and work within a team
- Microsoft Office skills
- Exceptional analytic, consultative, and critical thinking skills and attention to detail
- Excellent written and oral communication skills
- Project management experience preferred
- Experience in health care
- Ability to express complex analytical information to senior management or to audiences with clinical training


Qualifications:

Basic Qualifications:
- Five (5) to eight (8) years of related experience.
- Four (4) year degree in a relevant field or equivalent experience required.
- Master's degree preferred.
- Consider clinical expertiseneeds.
- Thorough knowledge of policies, practices and systems.
- Complete understanding and application of principles, concepts, practices, and standards.
- Full knowledge of industry practices.
- Broad application of principles, theories, and concepts in applicable discipline, plus working knowledge of other related fields.]]> Thu, 19 Apr 2012 16:00:00 GMT 2365341-Oakland-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Manages credentialing, proctoring, privileging, & reappointment process for Licensed Independent Practitioners (LIPs) & Allied Health Professionals
- Creates operations & communications processes that support organizational strategies & business objectives
- Supervises Medical Staff Services office include budget management, hiring, training, & counseling staff, equipment management, & quality of service
- Acts as a liaison, technical advisor, & resource person for the professional & allied staff, administration within each site
- Provides consulting services regarding regulatory, legal, accreditation, Program, & Regional credentialing standards throughout the region
- Hires, trains, counsels, & supervises all medical staff services office personnel
- Develops & implements mechanisms to ensure compliance to all regulatory agencies & the Professional Staff By-laws, Rules & Regulations
- Assists in the development of policies, procedures, protocols, & privileges to support the credentialing process & makes recommendations for bylaws revision
- Interprets requirements & disseminates information to all involved parties to assure necessary compliance, compatibility, & continuous quality improvement of the credentialing process
- Partners w/ appropriate Program, Regional, Service Area, Medical Group individuals & groups, accrediting bodies, & external consultants to develop & implement systems & processes that meet requirements & adhere to Regional Credentialing Policies & Procedures
- Collaborates w/ inter-regional peers to identify & implement best practices
- Supports committees as assigned

Qualifications:

Basic Qualifications:
- Minimum three (3) years of supervisory experience preferred
- Minimum five (5) years of experience in health care in an administrative or managerial position related to credentialing and/or accreditation
- Relevant bachelor's degree or four (4) years of equivalent experience required
- Certification in the area of Medical Staff Services, or Quality arena, preferred
- Significant working knowledge of federal and state regulatory requirements and accreditation standards (e.g., JCAHO, NCQA, DOC, DHS, Titles 22 and 16)]]> Sun, 15 Apr 2012 16:00:00 GMT 2351500-Los-Angeles-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Plans, develops, assesses & evaluates care provided to members.
- Collaborates w/ physicians, other members of the multidisciplinary health care team & patient/family in the development, implementation & documentation of appropriate, individualized plans of care to ensure continuity, quality & appropriate resource use.
- Assesses high risk patients in need of post-hospital care planning.
- Develops & coordinates the implementation of a discharge plan to meet patient's identified needs; communicates the plan to physicians, patient, family/caregivers, staff & appropriate community agencies.
- Reviews, monitors, evaluates & coordinates the patient's hospital stay to assure that all appropriate & essential svcs are delivered timely & efficiently.
- Participates in the Bed Huddles & carries out recommendations congruent w/ the patient's needs.
- Coordinates the interdisciplinary approach to providing continuity of care, including utilization mgmt, transfer coordination, discharge planning, & obtaining all authorizations/approvals as needed for outside svcs for patients/ families.
- Conducts daily clinical reviews for utilization/quality mgmt activities based on guidelines/standards for patients in a variety of settings, including outpt, ER, inpt & non-KFH facilities.
- Acts as a liaison between inpt facility & referral facilities/agencies & provides case mgmt to patients referred.
- Refers patients to community resources to meet post-hospital needs.
- Coordinates transfer of patients to appropriate facilities; maintains & provides required documentation.
- Adheres to internal & external regulatory & accreditation requirements & compliance guidelines including but not limited to: JCAHO, DHS, HCFA, CMS, DMHC, NCQA & DOL.
- Educates members of the healthcare team concerning their roles & responsibilities in the discharge planning process & appropriate use of resources.
- Provides patients w/ education to assist w/ their discharge & help them cope w/ psychological problems related to acute & chronic illness.
- Reviews, analyses & identifies utilization patterns & trends, problems or inappropriate utilization of resources & participates in the collection & analysis of data for special studies, projects, planning, or for routine utilization monitoring activities.

Qualifications:

Basic Qualifications:
- Minimum two years clinical experience as an RN in an acute care setting required.
- Bachelor's degree in nursing or healthcare related field preferred or current equivalent related work experience.
- Graduate of an accredited school of nursing required.
- Current and valid California RN license required.
- Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques and methods of utilization review/management, discharge planning and case management.
- Working knowledge of regulatory requirements and accreditation standards (JCAHO, Medicare, Medi-Cal, etc.).
- Demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking and problem-solving skills.

Preferred Qualifications:
- BLS / CPR certified.
- Emergency Room Experience
- Previous Clinical Experience (minimum two [2] - three [3] years) in an acute medical center.
- Previous experience in UM, Discharge Planning and or Case Management.
- Demonstrate ability to utilize written and verbal communication, interpersonal, critical thinking and problem solving skills.
- Collaborates with and provides direction to the physician, other members of the multidisciplinary health care team and patient / family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use.
- Per established protocols, reports any incidence of unusual occurrences related to quality, risk and / or patient safety which are identified during case review or other activities.
- Independently identifies and assesses high-risk patients in need of post-hospital care and follow-up, using UM criteria, guidelines, high risk screens, clinical judgments, etc as appropriate.
- Able to multi-task in a fast paced environment.


Notes:
- This is an on-call position; schedule / days / hours may vary.
- Work hours will vary between 9:00 pm - 7:30 am.]]> Tue, 10 Apr 2012 16:00:00 GMT 2339300-Ontario-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Plans, develops, assesses & evaluates care provided to members.
- Collaborates w/ physicians, other members of the multidisciplinary health care team & patient/family in the development, implementation & documentation of appropriate, individualized plans of care to ensure continuity, quality & appropriate resource use.
- Assesses high risk patients in need of post-hospital care planning.
- Develops & coordinates the implementation of a discharge plan to meet patient's identified needs; communicates the plan to physicians, patient, family/caregivers, staff & appropriate community agencies.
- Reviews, monitors, evaluates & coordinates the patient's hospital stay to assure that all appropriate & essential svcs are delivered timely & efficiently.
- Participates in the Bed Huddles & carries out recommendations congruent w/ the patient's needs.
- Coordinates the interdisciplinary approach to providing continuity of care, including utilization mgmt, transfer coordination, discharge planning, & obtaining all authorizations/approvals as needed for outside svcs for patients/ families.
- Conducts daily clinical reviews for utilization/quality mgmt activities based on guidelines/standards for patients in a variety of settings, including outpt, ER, inpt & non-KFH facilities.
- Acts as a liaison between inpt facility & referral facilities/agencies & provides case mgmt to patients referred.
- Refers patients to community resources to meet post-hospital needs.
- Coordinates transfer of patients to appropriate facilities; maintains & provides required documentation.
- Adheres to internal & external regulatory & accreditation requirements & compliance guidelines including but not limited to: JCAHO, DHS, HCFA, CMS, DMHC, NCQA & DOL.
- Educates members of the healthcare team concerning their roles & responsibilities in the discharge planning process & appropriate use of resources.
- Provides patients w/ education to assist w/ their discharge & help them cope w/ psychological problems related to acute & chronic illness.
- Reviews, analyses & identifies utilization patterns & trends, problems or inappropriate utilization of resources & participates in the collection & analysis of data for special studies, projects, planning, or for routine utilization monitoring activities.

Qualifications:

Basic Qualifications:
- Minimum two years clinical experience as an RN in an acute care setting required.
- Bachelor's degree in nursing or healthcare related field preferred or current equivalent related work experience.
- Graduate of an accredited school of nursing required.
- Current and valid California RN license required.
- Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques and methods of utilization review/management, discharge planning and case management.
- Working knowledge of regulatory requirements and accreditation standards (JCAHO, Medicare, Medi-Cal, etc.).
- Demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking and problem-solving skills.

Preferred Qualifications:
- BLS / CPR certified.
- Emergency Room Experience
- Previous Clinical Experience (minimum two [2] - three [3] years) in an acute medical center.
- Previous experience in UM, Discharge Planning and or Case Management.
- Demonstrate ability to utilize written and verbal communication, interpersonal, critical thinking and problem solving skills.
- Collaborates with and provides direction to the physician, other members of the multidisciplinary health care team and patient / family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use.
- Per established protocols, reports any incidence of unusual occurrences related to quality, risk and / or patient safety which are identified during case review or other activities.
- Independently identifies and assesses high-risk patients in need of post-hospital care and follow-up, using UM criteria, guidelines, high risk screens, clinical judgments, etc as appropriate.
- Able to multi-task in a fast paced environment.


Notes:
- This is an on-call position; schedule / days / hours may vary.
- Work hours will vary between 9:00 pm - 7:30 am.]]> Tue, 10 Apr 2012 16:00:00 GMT 2339299-Fontana-Quality-Assurance,-Utilization-Review,-or-Case-Management
Essential Functions:
- Assists in developing & maintaining policies & procedures for the Service Area or Medical Center related to Utilization Management
- Collaborates with the multi-disciplinary teams to plan & coordinate care across the continuum
- Coordinates & manages members' care with non-KFH hospital facilities & providers
- Identifies risk management & quality of care issues across the continuum
- Surfaces issues & any suggestions to the appropriate multi-disciplinary team members
- Manages transportation program to ensure appropriate utilization of resources which meet Health Plan guidelines & patient needs
- Assures compliance with Federal, State, JCAHO, NCQA, other regulatory agencies, & internal standards & requirements
- Provides direction to staff regarding utilization review, care coordination, discharge planning, & other services across the continuum of care
- Assists in conducting statistical studies in utilization trends, patterns, & outcomes
- Hires, trains coaches, disciplines professional & clerical support staff

Qualifications:

Basic Qualifications:
- At least three (3) - five (5) years of experience in utilization management and discharge planning in an acute care setting which also includes previous supervisory or management experience
- BSN or BA or BS degree in healthcare related field such as management, health services administration
- Current California RN license
- Demonstrated knowledge of operations and healthcare management; JCAHO, Title XXII, Medicare, MediCal, and other local, state and federal regulations
- Knowledge of managed care operations
- Demonstrated interpersonal, negotiation, and management skills
- Good oral and written communication skills

Preferred Qualifications:
- Master in Nursing with focus on administration, business or related health field; certification in Case Management;
- Previous supervisory/management experience in a managed care setting.
- Knowledge of health plan guidelines and other Utilization Management inpatient regulatory requirements, e.g., IM, Denial Letter process, AB 1203, core measures.
- Experience working with data base and experience with statistical trends, patterns and outcomes.]]> Tue, 10 Apr 2012 16:00:00 GMT 2339271-California-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Supervises the daily quality activities, ensuring timely & accurate data collection, and follow up of issues & quality of work
-Coaches staff & ensures their competency
- Coordinates & facilities staff support to various committees (e.g., quality, accreditation) which includes agenda preparation & monitoring of outstanding issues
- Provides reports based on timely & accurate data collection, identifies trends & monitors issues
- Develops implements & monitors quality department's policies & procedures; ensures they are in compliance w/ The Joint Commission, NCQA, CME, federal, state & local requirements
- Assists in developing & revising QA monitors to meet accreditation/regulatory standards
- Monitors the budgets, researches variances, & identifies opportunities to reduce costs
- Develops, implements, coordinates, & evaluates the CME programs, credentialing & privileges for permanent or temporary physicians & allied health providers
- Assists in preparation of educational materials & course objectives
- Maintains link between medical staff affairs & quality improvement, risk management, and continuing medical staff education
- Coordinates & prepares for CME, accreditation, licensing, & quality surveys/audits
- Maintains & monitors the various quality databases which may include quality reviews, CME, credentials & privileges, & provider profiles


Qualifications:

Basic Qualifications:
- Significant (typically 2-3 yrs) quality improvement or accreditation experience required
- Bachelor's degree or equivalent experience in a health care related field or business administration
- Previous supervisory experience recommended
- Ability to perform statistical analysis
- Current knowledge of The Joint Commission, NCQA, federal, state, & local requirements
- Knowledge & experience in application of adult learning theory in program development
- Must be able to work in a Labor/Management Partnership environment
]]> Thu, 05 Apr 2012 16:00:00 GMT 2329284-Roseville-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Provides strategic support to achieve high level of quality performance through collaboration with local leaders and regional initiatives and standardization to improve health.
- Accountable for the annual development, implementation, and evaluation of the Infection Prevention goals and objectives, plan, and risk assessment to reduce and control the risk of health care associated infections.
- Collaborates with leadership team to ensure compliance with regulatory and accrediting agency requirements, timely and accurate reporting to Department of Public Health and other external agencies as appropriate.
- Provides leadership to physician leaders, patient care service leaders and quality leaders to improve patient safety.
- Provides consultation to medical center leaders and staff. Actively participates in leadership meetings to ensure alignment of priorities and strategies.
- Provides direct supervision to Infection Prevention Coordinator(s) and Associate.
- Accountable for departmental budget.
- Co-chairs the Infection Control Committee with the Infectious Disease Chief to provide leadership which will ensure surveillance activities and improvement plans are analyzed, implemented and reported to leadership.
- Collaborates with Occupational/Employee Health to institute measures to protect and prevent healthcare workers from injuries due to communicable diseases.
- Collaborates with Facility Services to ensure an integrated Environment of Care program.
- Keeps abreast of current scientific literature, recommendations, guidelines, and regulatory requirements which may impact the Infection Prevention Program.
- Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees.

Secondary Functions:
At one medical center (including all associated ambulatory care departments/sites and other non-acute patient care sites), accountable for the management of a Infection Prevention and Control Program across the continuum of care, developing and achieving Infection Control goals and objectives, planning, developing, implementing, delivering, evaluating and continuously improving infection prevention and control services. In a facility with a staff of one or more IC Coordinators and/or IC Associates, responsible for program design, planning, implementation, evaluation and for directing the work of the IC Coordinator(s) and any other assigned staff, for serving as the content expert/consultant in Infection Control and Prevention for one entire medical center and associated ambulatory care areas. Also accountable for collection and analysis of healthcare associated infection data, development and presentation of reports and educational programs for personnel and patients as needed, ensuring provision of requested KP patient information to the Department of Health Services, recommending to local leadership/Risk Management when Public Health/Dept of Health should be notified in the event of an outbreak, management of infection prevention and control practices, assisting client departments in survey readiness and preparation for regulatory standard reviews, accreditation and licensure surveys in both the acute and ambulatory care areas (e.g. The Joint Commission, Cal-OSHA, DHS, etc.).

Qualifications:

Basic Qualifications:
- Minimum three (3) years of infection prevention experience in an acute health care facility.
- Three (3) to five (5) years of progressively more responsible related work experience with two (2) years current management experience in assigned service area preferred; or completion of management training program required.
- Bachelor's degree in a health related field such as Nursing, Epidemiology, Microbiology or Public Health.
- Master's degree preferred in Nursing, Epidemiology, Microbiology, Public Health or other discipline.
- Current Certification in Infection Control (CIC) preferred, or must become certified within the first year of hire.
- Valid California license or certification in clinical healthcare discipline preferred, such as nursing, clinical laboratory science, or public health.
- Demonstrated leadership skills.
- Demonstrated skills in program management, project management, time management, and/or resource management.
- Demonstrated ability to influence change.
- Demonstrated skills in collaborative team work.
- Demonstrated problem-solving, analytic, and decision making skills.
- Demonstrated written and oral communication skills.
- Demonstrated ability to develop and present educational programs.
- Demonstrated ability to apply adult learning principles.
- Demonstrated computer software application skills such as Lotus Notes, Words, Excel, and Powerpoint.

Preferred Qualifications:
- Minimum of two years (usually) experience as an Infection Control Coordinator.
- Minimum of four years relevant clinical experience in an acute care hospital, utilizing knowledge of medical andsurgical procedures as well as techniques and procedures involved in patient care, treatment and management.
- Demonstrated knowledge of microbiology, laboratory procedures, adult education, aseptic technique and epidemiological techniques.
- Demonstrated ability to comprehend and utilize epidemiological/public health data and statistical methods, screen and interpret data results for variations and/or errors.]]> Thu, 05 Apr 2012 16:00:00 GMT 2329259-Roseville-Quality-Assurance,-Utilization-Review,-or-Case-Management Kaiser Permanente
Oakland, CA

These positions manage projects and programs to achieve an effective and reliable infrastructure to meet the goals and objectives of hospital and health plan quality oversight. Accountable for managing all phases of improvement projects including design, prioritization, staffing, development, implementation, analysis, metrics, and reporting. Prepares reports on appropriate oversight areas including patterns, trends, and organizational risk. Coordinates and delivers education, training, and communication programs. Develops program-wide templates for appropriate policies and procedures and ensures implementation for consistent programs and infrastructures across the enterprise. Functions as an expert authority to all entities in regions. At the highest level of the job family, shares in accountability of outcomes and performance for all regions and the enterprise in oversight areas and demonstrate in-depth practice, knowledge, and skills, manage projects and programs, and are accountable for the successful execution of goals that are aligned with the goals of QRM in promoting the KP National Quality Program.
Essential Functions:
- Works on assignments of diverse and complex scope.
- Assists the Director in developing and executing goals that promote the success of overall QRM goals related to analytical deliverables and by evaluating established and emerging care practices.
- Identifies the need for, develops, and leads discrete strategic initiatives, including but not limited to:
- Develops and manages project teams.
- Reassesses and modifies program deliverables.
- Ensures that programs are designed to achieve stated objectives.
- Leads work to identify appropriate evidence-based organizational goals in area of expertise and makes recommendation to Director and/or appropriate committee.
- Leads peer group meetings and programs that interface with targeted areas of expertise.
- Monitors multiple projects and teams to ensure timely delivery of expected work product within approved budget.
- Establishes and maintains effective working relationships with national and regional groups.
- Assists regions in developing priorities, aims and plans, and provides coaching and advice to colleagues on successful implementation strategies.
- Participates on regional or national work groups.
- Ensures customer service orientation both internally and externally.
- Makes formal presentations to various senior-level audiences.
- Develops and delivers presentations, educational materials, and position papers to all levels of leadership and management regarding program wide performance, programs, and project.
- Integrates industry trends and best practices throughout programs, projects, and goals.
- Consider appropriate compute skills necessary to perform job.
- Responsibilities impact the achievement of key functional and/or KP objectives that have direct and significant business impact.
- Contributes to the development of the department's objectives.
- Erroneous decisions or recommendations would normally result in the inability to reach functional objectives and negatively affects expenditures and resources.
- Involves interpreting and analyzing established concepts and trends.
- Exercises considerable judgment to make decisions for less defined and complex issues.
- Develops solutions to a diverse range of complex problems, which require creativity and innovation within broadly defined policies and practices.
- Assume other duties as directed.

Qualifications:

Basic Qualifications:
- Eight (8) to twelve (12) years of related experience.
- Four (4) year degree in a related field or equivalent experience.
- Thorough knowledge of policies, practices and systems.
- Regularly contributes to the development of new concepts, techniques, and standards.
- Considered functional expert in field within KP.
- Frequently contributes to the development of new theories and methods.
- Employs expertise as a generalist or specialist.
- Master's Degree required]]> Wed, 04 Apr 2012 16:00:00 GMT 2325040-Oakland-Quality-Assurance,-Utilization-Review,-or-Case-Management To assure that only credentialed practitioners & providers render care to KP members & that all practitioners, providers & delegates meet KP regulatory & accreditation standards.
Essential Functions:
- Process Management – Initiates & follows through on all aspects of credentialing including the initial & re-credentialing process for all practitioners employed &/or contracted w/ Kaiser Permanente of the Mid-Atlantic States. In addition, initiates & follows through on all aspects of the privileging & re-privileging of Mid-Atlantic Permanente Medical Group physicians w/ Ambulatory Surgery Center (ASC) privileges.
- Initiates & conducts primary source verification of practitioner's background, education/training & malpractice history through the use of on-line systems, written correspondence, telephone inquiries & printed reference guides, rosters & reports.
- Identifies & evaluates potential red flags & works in collaboration w/ department Manager/Director, &/or Physician Managers to determine next steps.
- Performs List Validation & Reporting (LVAR) queries per the National Compliance Office & Regional Compliance department & in compliance w/ federal & state regulations.
- Performs analysis of report data & state board sanction information in compliance w/ regulatory on-going monitoring requirements.
- Is responsible for preparation of materials & files for presentation & review by the Mid-Atlantic States Credentialing & Privileging (MASCAP) committee.
- Coordinates approval of identified clean files at weekly electronic meetings of the MASCAP committee & initiates notification of committee decision to practitioner w/ appropriate follow-up to Provider Relations & Provider Contracting.
- Collaborates w/ inter-departmental peers, including Quality Management, Provider Relations, & Provider Contracting & Data Management to identify & implement best practices & to ensure an integrated, timely, & consistent product.
- Partners w/ MAPMG Human Resources to ensure timely credentialing of new physicians prior to employment. Reviews “locum tenen” profile information & coordinates notification of approval to department service chiefs.
- Customer Focus/Communication Skills – Provides assistance & determines resolution to practitioner issues &/or triages appropriately, via verbal/written communication in response to both internal & external customers.
- Functional Skills – Ensures compliance w/ NCQA standards & other regulatory agencies. Assists in the development of policies & procedures to support the credentialing process.
- Technical Skills - Responsible for the accuracy & integrity of the credentialing database. Able to run database queries & reports to support efficiencies & prioritization of work flow.
- Problem Solving Skills – Identifies & responds pro-actively to issues & concerns assuring complete solutions in a timely manner.
- Organizational Skills – Ability to juggle multiple priorities & perform expedited credentialing upon request.


Qualifications:

Basic Qualifications:
- 3 years of credentialing experience in a managed care setting required.
- Bachelor’s degree / 4 years of relevant experience required.
- Proven ability to function independently w/ minimal direct supervision required.
- Significant working knowledge of Federal & State regulatory requirements & accreditation standards, including NCQA, CMS, COMAR & MCHIP required.
- Strong organizational & communication skills required.
Preferred Qualifications:
- Knowledge of Visual Cactus preferred.
- Certification as Certified Provider Credentialing Special (CPCS) preferred
]]> Tue, 03 Apr 2012 16:00:00 GMT 2320823-Rockville-Quality-Assurance,-Utilization-Review,-or-Case-Management Medical Audit Coordinator - Appeals, RN
Oakland, CA

Review claims for services obtained outside of Kaiser Facilities for compliance w/ health plan service agreement with members; identifies health plan claims w/ potential quality of care issues, continuity of care problems, or access issues at medical facilities; & audits hospital billings on site at non-plan provider facilities & negotiates successful resolution of claim.

Essential Functions:
- Provides clinical expertise to members of the Special Servies unit and other departments such as Workers Comp., TPMG referrals, CSA/MSA outside case management in areas related to hospital and physician billing practices and cost department activities.The Medical Audit Coordinator for the Special Service unit reviews claims for services obtained outside of Kaiser facilities for compliance with health plan service agreement with members; identifies health plan claims with potential quality of care issues, continuity of care problems, or access issues at medical facilities; and audits hospital billings on site at non Plan provider facilities and negotiates successful resolution of claim.
- Works with Appeals Specialist as a resource for decision-making and medical terminology.
- Plans, organizes daily work to meet compliancre timeframes. Provides feedback to manager to ensure works is within compliance.
- Works with Appeals Specialist as a resource for decision-making and medical terminology.
- Prepares case narratives for appeals being forwarded to the IRE
- Plans, organizes daily work to meet compliancre timeframes. Provides feedback to manager to ensure works is within compliance.
- Provides clinical expertise to other departments such as Workers Compensation, TPMG referrals, CSA/MSA outside case management in areas related to hospital & physician billing practices & cost containment activities
- 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 integrety, reporting non compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanente's policies and procedures.
- Works w/ legal department when indicated to resolve payment disputes.
- Serves as a consultant to CSA Continuing Care teams & case managers on issues of non-plan pricing, billing problems, procedures & benefit compliance issues. Identifies opportunities for cost containment. Works with regulatory compliance for review of benefit.
- Responsible for review ICD-9, CPT codes, medical records, UB-92 & HCFA forms & KP internal systems (OTRS, Advice call logs). Determines if bills are payable or if additional information is needed, if there are potential fraud issues.
- Works w/ PRS staff as a resource for decision-making & medical terminology.
- Plans & organizes daily work to meet compliance timeframes. Provides feedback to manager to ensure work is w/in compliance.
- Consistently supports compliance & the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy & confidentiality of information, protecting the assets of the organization.
- Acting w/ ethics & integrity, reporting non-compliance, & adhering to applicable federal, state & local laws & regulations, accreditation & licenser requirements (if applicable), & KP's polices & procedures.
- Identifies areas of special need for review or takes on additional review/projects as assigned by the manager.
- Assists in the training of new medical auditors.
- Responsibilities impact HPA compliance commitments to regulatory agencies such as CMS, DMHC, DHS, NCQA.
- Erroneous decisions may negatively impact member satisfaction, the organization's regulatory compliance commitments & financial status.
- Decisions are made following state & federal regulations related to provider reimbursement for claims, NCQA standards, KP's internal policies related to payment of out-of-plan services.
- Decisions are made to pay claims or refer to physician advisor based on clinical criteria related to emergency medical condition.
- Payable claims are analyzed for correct contract interpretation, Medicare fee schedule interpretation, correct coding.
- Coordinator uses independent judgment based on business related knowledge in deciding which claims should be paid & on any payment reductions.
- Analyzes information from multiple internal & external sources when reviewing a claim episode of care.
- Assigns work based on regulator compliance, staffing, staff skill level & completing priorities.
- Train new medical audit coordinators. Serves as resources to less experienced coordinators.
- Serves as a consultant to CSA Continuing Care teams & case managers on issues on non-plan pricing, billing problems, procedures & benefit compliance issues.
- Works w/ interregional counterparts for matters of billing resolutions & clinical issues & w/ regulatory department regarding issues of compliance & interdepartmental review of benefit issues
- Assume other duties as assigned


Qualifications:

Basic Qualifications
- Minimum five (5) years of clinical experience, preferably in critical care; the ability to make timely, sound decisions, and to act independently and negotiate successful resolution in difficult situations.
- Minimum two (2) years of experience in medical auditing or related business experience.
- Preferred: Advanced work in ICD-9 and/or CPT coding, Medicare rules application, DRG coding knowledge as demonstrated by related certifications or on job performance.
- Required: Graduate of an accredited Nursing Program.
- Preferred: Bachelor's degree OR equivalent.
- Current California RN license.
- Preferred: Certificate in Coding and Certificate in AAMA.
- Must have demonstrated ability to work independently and make quick decisions with a high degree of competency utilizing multiple sources of information.
- Competency in Microsoft Suites (Excel, Access, Power Point), excellent ability with proprietary, mainframe processing systems and KP technologies.
- Demonstrates strong understanding of medical terminology, ICD-9 coding, CPT coding principles.
- Knowledge of LMP required and ability to work in LMP environment.
- Strong customer service skills.
- Must understand DHS, Medicare, ERISA, DMHC, NCQA guidelines for payment of claims.
- State regulations pertaining to member and provides appeal rights required.
- Understand billing practices and guidelines as defined by organizations such as National Association of Insurance Companies, American Association of Medical Audit Specialists.

]]> Sun, 25 Mar 2012 16:00:00 GMT 2297025-Oakland-Quality-Assurance,-Utilization-Review,-or-Case-Management Kaiser Permanente
Oakland, CA

Kaiser Permanente is seeking a Liver Transplant Coordinator who will be vital to the success of National Transplant Services NCAL Hub's Transplant Program in ensuring KP members receive the quality transplant care throughout the transplant continuum. The transplant coordinator oversees the quality of care and case management of transplant candidates throughout the pre- transplant, and post-periods.

Essential Functions:
- Coordinates case management to include, but not limited to, continuity of care, inpatient and outpatient care, utilization management, transfer coordination, discharge planning, travel and lodging, and concurrent review.
- Identifies, reports, and monitors quality of care issues, trends, and events, as well as other information on the key elements of the quality program occurring both internally and within Centers of Excellence that relate to the delivery of care to transplant patients.
- Maintains current knowledge in the field of transplantation and integrates this knowledge into the assessment of needs and problem solving required to manage across the continuum.
- Establishes and maintains effective partnerships between KP and Centers of Excellence with the goal of providing total quality and case management for KP members receiving transplant services.
- Assists in development and maintenance of educational materials for the KP transplant program, including but not limited to, information for members, families, physicians, and Centers of Excellence. Position may participate in operational and educational meetings with Centers of Excellence and KP Regions. Some travel may be required.
- Position is responsible for providing cross coverage across the transplant areas managed by this Hub to ensure members receive quality care, cost effectively, and efficiently. Effective and efficient case management brings a multitude of services together to ensure a comprehensive system for care is in place. When services are successfully integrated, quality care and successful outcomes are achieved.
- There is a managerial role assigned to a case manager which refers to the scope of responsibility it takes to coordinate the care of patients, including problem-solving and overcoming hurdles that may be identified. Decisions must be made relative to goal identification and achievement, as well as resources required to meet the needs of the patient. Incumbent must be able to utilize the nursing process to identify barriers to care and select appropriate solutions from potential options for intervention, based on a set of complex and individual patient needs. This includes identifying cultural and linguistic needs and incorporating actions to address such needs in the case management plan. Must also be able to provide age appropriate care.

Qualifications:

Basic Qualifications:
- 3 years of inpatient experience or 3 years of case management or utilization management experience
- 3 years of experience in transplantation, critical care, as well as case management experience
- Bachelor's degree
- RN License
- Critical thinking skills required in order to make judgments based on facts and scientific principles
- Business skills necessary for leadership ability, internal and external professional communication (both written & verbal), internal and external negotiation, regulatory and legislative knowledge, planning and outcome analysis.
- Accountability means having the ability to practice independently
- Tracking in order to evaluate care plans and strategies implemented through the case management process
- PC & keyboarding proficiency required to meet standards for documentation of medical history and care

Preferred Qualifications:
- Transplant knowledge preferable
- Experience with KP systems a plus]]> Wed, 21 Mar 2012 16:00:00 GMT 2288500-Oakland-Quality-Assurance,-Utilization-Review,-or-Case-Management Kaiser Permanente
Oakland, CA

Kaiser Permanente is seeking a Transplant Coordinator who will be vital to the success of National Transplant Services NCAL Hub's Transplant Program in ensuring KP members receive the quality transplant care throughout the transplant continuum. The transplant coordinator oversees the quality of care and case management of transplant candidates throughout the pre-transplant, and post-transplant periods. This position will serve as a float nurse covering all transplant types managed by the Hub andproviding coverage for staff on vacation or leave.
Essential Functions:
- Coordinates case management to include, but not limited to, continuity of care, inpatient and outpatient care, utilization management, transfer coordination, discharge planning, travel and lodging, and concurrent review.
- Identifies, reports, and monitors quality of care issues, trends, and events, as well as other information on the key elements of the quality program occurring both internally and within Centers of Excellence that relate to the delivery of care to transplant patients.
- Maintains current knowledge in the field of transplantation and integrates this knowledge into the assessment of needs and problem solving required to manage across the continuum.
- Establishes and maintains effective partnerships between KP and Centers of Excellence with the goal of providing total quality and case management for KP members receiving transplant services.
- Assists in development and maintenance of educational materials for the KP transplant program, including but not limited to, information for members, families, physicians, and Centers of Excellence. Position may participate in operational and educational meetings with Centers of Excellence and KP Regions. Some travel may be required.
- Position is responsible for providing float coverage across the transplant areas managed by this Hub to ensure members receive quality care, cost effectively, and efficiently. Effective and efficient case management brings a multitude of services together to ensure a comprehensive system for care is in place.
- There is a managerial role assigned to a case manager which refers to the scope of responsibility it takes to coordinate the care of patients, including problem-solving and overcoming hurdles that may be identified. Decisions must be made relative to goal identification and achievement, as well as resources required to meet the needs of the patient. Incumbent must be able to utilize the nursing process to identify barriers to care and select appropriate solutions from potential options for intervention, based on a set of complex and individual patient needs. This includes identifying cultural and linguistic needs and incorporating actions to address such needs in the case management plan. Must also be able to provide age appropriate care.

Qualifications:

Basic Qualifications:
- 3 years of inpatient experience or 3 years of case management or utilization management experience
- 3 years of experience in transplantation, critical care or oncology, as well as case management experience
- Bachelor's degree
- RN License
- Critical thinking skills required in order to make judgments based on facts and scientific principles
- Business skills necessary for leadership ability, internal and external professional communication (verbal and written), internal and external negotiation, regulatory and legislative knowledge, planning and outcome analysis.
- Accountability means having the ability to practice independently
- Tracking in order to evaluate care plans and strategies implemented through the case management process
- PC & keyboarding proficiency required to meet standards for documentation of medical history and care

An individual should have the following core behaviors:

Champions Innovation and Change
Collaborates
Communicates Effectively
Develops Self/Others
Drives for Results
Focuses on the Customer
Takes Accountability
Demonstrates Business Acumen
Exerts Influence
Emotional Intelligence*

Preferred Qualifications:
- Transplant and/or oncology knowledge preferable
- Experience with KP systems a plus]]> Wed, 21 Mar 2012 16:00:00 GMT 2288433-Oakland-Quality-Assurance,-Utilization-Review,-or-Case-Management
Essential Functions
- Provide analytical services to coordinating analysts and multiple project teams, facilitate large / region-wide / national requests and oversee all data and submission issues related to the Quality/Patient Safety, Population Health/QRM/HIMS departments.
- Acts as a coach / mentor for Project Managers, Senior Analysts, Analysts and/or Data Delivery Specialists. Position may also include a supervisory role over a minimum of (1) staff person from Senior Analyst, Analyst or Data Delivery Specialist positions.
- Serve as a clinical, including DxCG and ETG, data Subject Matter Expert (SME) to consult with business owners on departmental operations and the data used to support operations.
- Support departments and interdisciplinary groups by facilitating the acquisition of data and information needed to drive Regional and operational decision making and process improvements.
- Actively participate as a project team member as required (for Quality Workgroup or other strategic initiatives).
- Oversee and ultimately assign activities to obtain, analyze, organize and interpret data into actionable recommendations and conclusions.
- Facilitate report production or data process development.
- Assists in information systems development including the design and management of data sources.
- Assist in distribution of report deliverables including intranet web postings for easy client access.
- Document business learning's and actively work to share knowledge across analyst pool.
- Identify and communicate data gaps in the organization.
- Maintains a broad spectrum of knowledge regarding business processes and the underlying systems and data sources that support these processes.
- Project management role as assigned which includes developing a project workplan that identifies the process, work steps, assigned individuals and timeframes. Scope of project can be as large as Lead role in HEDIS reporting and external audit preparation; a project that impacts organization across all Clinical Departments in terms of NCQA Accreditation and clinical performance quality improvement efforts.
- Master complex software packages to perform SQL interface programming as well as relational query writing across data sets. Knowledge of database design within data warehouse as well as other data sources should be applied to improve data processing efficiencies.
- Demonstrate experience with consolidating data in a cross functional environment (i.e. membership; claims; lab; etc. ).

Qualifications:

Basic Qualifications
- Bachelor's Degree required in business, statistical, accounting, management or related field; OR (5) years of equivalent experience in project management / organizational management in a health care provider or payer organization.
- Academic or relevant work experience to strongly demonstrate leadership, organization and project management.
- Must have in-depth familiarity with the corporate data environment / data warehouse structure. Use of relational databases and end-user tools (e.g. SQL language) to develop interfaces that support executive information requirements valuable to Senior Management, Chiefs of Service, department managers, and supervisor.
- 5 Years experience managing data analysis functions within a comparable organization.
- Experience in managing multiple requests and directing the work of others.
- Proficient in computer word processing and data analytics tools such as Cognos, Paradox or similar database.

Preferred Qualifications
- Master's Degree from accredited university / college in IT, business, statistical, accounting, management or related field plus (4) years experience in data analysis in a health care provider or payer organization.
- Technical training on data analysis applications.
- Health Care delivery or managed care experience.
- Experience in Business Intelligence Tools such as SAS (or related) or in coding and using SQL is preferred but not required.]]> Thu, 15 Mar 2012 16:00:00 GMT 2270859-Atlanta-Quality-Assurance,-Utilization-Review,-or-Case-Management
Essential Functions:
- Conducts utilization review for in-house patients as well as those members who have admitted to contracted facilities.
- Conducts clinical reviews based on established treatment criteria.
- Reviews utilization patterns, identifies trends and problems areas for special studies.
- Assists other health care providers in the discharge planning process and triaging on alternative unit of care.
- Assists in collecting and assimilating clinical data to enhance the quality of services.
- Generates quality improvement results.
- Collaborates with physicians on clinical reviews, keeps them appraised of Kaiser clinical criteria.
- Reports and investigates unusual occurrences and questions inappropriate decisions based on their professional expertise.
- Interviews patients/caregivers regarding care after hospitalization.
- Counsels on Medicare and health care plan coverage.
- Coordinates referrals to appropriate agencies/facilities.

Secondary Functions:
- Collaborates with the physician to evaluate new skilled admissions to SNF, to identify level of care required for the patient and to ensure that patient's care needs meet guidelines for SNF coverage.
- Collaborates with the physician and others to evaluate the patient's need for continued skilled services based on patient observation, participation in weekly interdisciplinary team meetings and concurrent chart reviews.
- Authorizes initial and extensions of SNF coverage in consultation with the physician based on skilled care criteria.
- Monitors patient's need for special equipment during the SNF stay and facilitates and tracks initiation/discontinuance of special equipment in consultation with the physician.
- Reviews medical and functional status and readiness for discharge. Monitors SNF discharge planning activities to assure a timely and coordinated discharge to the next level of care.
- Issues notices of non-coverage and other regulatory notifications to patients/families as required by regulatory and certification agencies.
- Collaborates with the appropriate Kaiser department to assure that coverage of DME, Orthotics & Prosthetics, pharmacy and therapies are converted from the SNF benefit to other coverage when appropriate.
- In collaboration with the physician and interdisciplinary team, the SNF Coordinator monitors and ensures coordination of care for Kaiser members in Skilled Nursing Facilities.
- Assures SNF has received all required documentation for appropriate care of patients (Physician Orders, Discharge Summary, etc.)
- Assures that discharge planning begins immediately, that the SNF D/C planner identifies discharge barriers ASAP and he/she addresses them in a timely manner.
- Reviews and ensures that the Plan of Care is being followed and identified goals are being met or revised.
- Clarifies D/C goal and plan with patient/family/SNF.
- Ensures arrangements have been made for other Kaiser services ordered by the physician (Medical Center/SNF follow up, Consults, Referrals, DME) upon admission, during the stay and at discharge. This includes appropriate transfer of care across the continuum (HH, Hospice, Case Management Programs, transportation and medical follow-up).
- Identifies and assists in resolution of psychosocial issues impacting the patients' care and recovery.
- Educates SNF staff related to Kaiser processes for referrals to alternate levels of care, medical.

Qualifications:

Basic Qualifications:
- Previous experience in an inpatient setting (usually 2 years).
- Previous experience utilization experience required (usually 1 year).
- Bachelors degree, or equivalent experience, in nursing or health related field required.
- Graduate of accredited school of nursing.
- Current California RN license.
- Demonstrated knowledge of diagnostic codes.

Preferred Qualifications:
- Clinical expert in area of review preferred.
- Masters degree preferred.
-Two out of the past five years of work experience in an acute care, home health, or SNF setting.
-Effective verbal, written, and interpersonal communication skills.
-Excellent clinical assessment skills.
-Excellent customer service skills.
-Basic independent computer skills.
- Valid CA Driver's License, vehicle or alternative transportation arrangements.
- Knowledge/experience in: Utilization Management, Case Management, Discharge Planning, and Quality Assurance.
- Knowledge of Kaiser Health Plan & Organization.
- Knowledge of regulation and accreditation requirements for SNF.
- Knowledge of community resources and levels of care available.]]> Wed, 14 Mar 2012 16:00:00 GMT 2262347-North-Bay-Quality-Assurance,-Utilization-Review,-or-Case-Management
Essential Functions:
- Designs and implements surveillance/prevention programs for hospital/Hospital Service Departments procedure-related infections
- Monitors and reports on infection trends in the hospital and hospital service departments. Develops applicable interventions
- Initiates epidemiological investigations of significant clusters of infection
- Institutes appropriate corrective action to protect patients and employees from transmission of communicable diseases
- Investigates patient, physician, staff, and visitor exposure to communicable disease at the Hospital and Hospital Service Departments. Coordinates follow-up of exposed persons
- Develops, implements, and conducts ongoing education programs in compliance with regulatory requirements and meeting customer needs
- Collaborates with Hospital leadership of outside agencies in case of infections or outbreaks of infection in members cared for in outside facilities
- Ensures Hospital compliance with bloodborne pathogen and TB exposure requirements of state and federal agencies
- Assists Hawaii State Department of Health in investigation of cases of communicable disease.
- Respresents and communicates the Hospital and Hospital Service Departments Infection Control issues and metrics on the Regional Infection Control Committee
- Serves as active member and consultant on various hospital and clinic committees
- Consults to hospital and clinic staff and patients
- Coordinates special projects (e.g., National Hand Hygiene Initiative)
- Collaborates with Quality, Safety & Service division on regional initiatives
- May perform patient care to the extent necessary to maintain clinical expertise, competency, and licensing necessary to fulfill job responsibilities and to direct the provision of care on the unit.
- Provides direct patient care on an as needed basis. Provides services that are within scope of license and in compliance with all legal, regulatory, and policy requirements relevant to clinical role performed
- Incorporates the KP Nursing Vision, Model and Values through out their Nursing Practice

Qualifications:

Basic Qualifications:
- Three years of infection control, medical laboratory, case finding surveillance, education, and/or prevention programs experience or related experience
- bachelor's degree in science or related field or equivalent related experience
- Valid Hawaii RN license (must meet education requirement(s) for Hawaii State licensure)
- Current BLS for Healthcare Provider CPR or CPR/AED for the Professional Rescuer certification
- Certified Infection Control Professional (CIC) by the Certification Board of Infection Control and Epidemiology, Inc. (CBIC) (must obtain within one year of hire)
- Demonstrated knowledge of relevant state, federal and accreditation agency requirements
- Demonstrated knowledge of and skill in influence, group presentations, oral communication, written communication, problem solving (e.g., analysis), quality management, and systems thinking]]> Sun, 11 Mar 2012 16:00:00 GMT 2239738-Honolulu-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Provides leadership and expert consultation on the design, development, and implementation of programs related to the expertise area.
- Leads a group of consultants, analysts and/or staff focused on the delivery of service/products within the responsible technical area(s).
- Provides leadership and direction for the technical area(s) in accordance with the overall strategic direction of the group.
- Serves as the content expert of the responsible technical area(s) and provides technical assistance and advice.
- Develops standards, procedures, and policies to ensure that the responsible unit is maintained according to the acceptable level of quality from clients.
- Ensures that reports and information disseminated from the area(s) are accurate, timely and consistent, and that they satisfy the clients' needs.


Qualifications:

Basic Qualifications:
- Typically six or more years of experience in a management or clinical leadership role required.
- BSN or BA in health related field required; Master's degree preferred.
- Current California nursing license required.
- Demonstrated ability to determine the key business issues and develop appropriate action plans from multidisciplinary perspectives.
- Demonstrated subject matter expertise in health care operations and care delivery.
- Ability to adapt to constantly changing priorities and managing a wide range of projects.
- Demonstrated ability to lead professionals and manage others through influence and collaboration.
- Demonstrated ability to conduct and interpret quantitative/qualitative information with analytical problem solving and project management.
- Proven leadership skills in consulting.
- Must exhibit efficiency, collaboration, candor, openness, and results orientation.
- Must demonstrate an understanding of the operations of KP, health policy trends, and any applicable regulations related to the responsible technical area.
- Must be able to work in a Labor/Management Partnership environment.
]]> Thu, 08 Mar 2012 14:00:00 GMT 1855569-Oakland-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Provides overall direction, design, development implementation, & monitoring of utilization programs to meet the Service Area's or Medical Center's utilization goals while maintaining customer satisfaction
- Acts as a resource to the medical staff, administrative staff, divisional, SCPMG, TPMG, & external regulatory agencies in all issues relating to utilization management within the Service Area or Medical Center
- Oversees outside medical services based on Health Plan benefit guidelines & medical necessity
- Analyzes & reports significant utilization trends, patterns, & impact to appropriate departmental & medical staff committees
- May direct the operations of outside referrals/transportation services
- May serve as contract liaison for the Service Area or Medical Center on issues pertaining to new or existing contracts w/ outside vendors
- Develops, monitors, & controls department's budgets
- Assures compliance w/ Federal, State, JCAHO, NCQA, other regulatory agencies, & internal standards & requirements
- Hires, coaches, trains, & disciplines staff to ensure smooth operations in utilization management
- Also facilitates educational training for medical staff on issues related to utilization management

Qualifications:

Basic Qualifications:
- Three (3) - five (5) or more years of experience in directing utilization management and discharge planning in an acute care setting
- BSN or BA or BS degree in healthcare related field such as management, health services administration
- Relevant master's degree in a related field such as nursing, business or health services administration preferred
- Current California RN license
- Demonstrated knowledge of operations and healthcare management; JCAHO, Title XXII, Medicare, Medi-Cal, and other local, state, and federal regulations
- Knowledge of managed care operations
- Demonstrated interpersonal, negotiation, and leadership skills
- Effective oral and written communication skills

Preferred Qualifications:
- Case Management Certificate
- Master's Degree in business or healthcare related field
- Computer skills in Word, Excel, and Powepoint]]> Mon, 05 Mar 2012 14:00:00 GMT 2226655-Los-Angeles-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Supervises staff including directing, motivating, guiding, providing resources, investigation & initiating corrective action as needed, to ensure harmony, team spirit, & quality delivery of services
- Supervises day-to-day activities, coordinates departmental services, & monitors appropriate outcomes
- Supervises operations including practice standards, staffing, payroll, budgets, fiscal management, & quality improvement
- Monitors the quality of service & utilization standards, assuming specific responsibility at the department level
- Acts as a liaison between the department & its customers (medical centers, outside facilities, members) to promptly resolve issues & to control unnecessary costs
- Oversees, educates, & directs staff in all aspects of the department's function to provide quality, member-focused services that meet clinical standards & regulatory guidelines
- Works in collaboration w/ the physician advisor to ensure smooth departmental functioning & adherence to clinical & quality standards
- Works in collaboration w/ Kaiser facility directors, administrators, & physician advisors regarding appropriate utilization of resources & coordination of services to maintain high quality & efficiency
- Works in collaboration w/ the CCC QA director to identify, trend, & provide feedback regarding quality issues
- Works in collaboration w/ other CCC department managers & supervisors to share successful practices & provide additional cross over supervisory responsibilities as needed
- Analyzes statistical reports to identify the effectiveness of the department's program, analyzes trends, monitors the utilization of resources, & acts on the information appropriately
- Ensures that all program activities are in compliance w/ the KP benefits & w/ the various regulatory agencies having influence over management of medical care & reimbursement & w/ government legislative directives

Qualifications:

Basic Qualifications:
- Three (3) years of prior management/ supervisory/ charge nurse experience
- Usually five (5) years of clinical nursing experience relevant to given position/department (e.g., critical care/ emergency room) required with usually three (3) years of previous experience in direct management/ supervisory and/or charge nurse position
- EPRP/COUM requires knowledge and understanding of utilization management principles with some UM experience preferred
- Bachelor' degree in nursing or related field
- TTM requires BCLS, ACLS, critical care and pacemaker certification, preferred
- Active California RN license
- Autonomous individual with little need for direct supervision
- Understanding of the HMO environment and knowledge of the integrated delivery model of care
- Knowledge of health care trends, provider types and reimbursement issues
- Thorough knowledge of CMS requirements, Title XXII regulations and other regulatory agency requirements relevant to given department
- Excellent verbal and written communication skills including team building and collaboration abilities
- Excellent problem solving skills and ability to manage diverse interests with minimal supervision
- Must be able to work in a Labor/Management Partnership environment
- Thorough understanding of Kaiser Systems including KFH, SCPMG and Health Plan including Medical Center Operations, regional policies and the Kaiser HMO philosophy, preferred

Preferred Qualifications:
- Computer Skills; Word, Excel, Powerpoint

Notes:
- Schedule Varies
- Rotating Weekends]]> Wed, 29 Feb 2012 14:00:00 GMT 2216812-California-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Provides strategic support to achieve high level of quality performance through collaboration with local leaders and regional initiatives and standardization to improve health. Accountable for the annual development, implementation, and evaluation of the Infection Prevention goals and objectives, plan, and risk assessment to reduce and control the risk of health care associated infections.
- Collaborates with leadership team to ensure compliance with regulatory and accrediting agency requirements, timely and accurate reporting to Department of Public Health and other external agencies as appropriate. Provides leadership to physician leaders, patient care service leaders and quality leaders to improve patient safety. Provides consultation to medical center leaders and staff. Actively participates in leadership meetings to ensure alignment of priorities and strategies. Provides direct supervision to Infection Prevention Coordinator(s) and Associate. Accountable for departmental budget. Co-chairs the Infection Control Committee with the Infectious Disease Chief to provide leadership which will ensure surveillance activities and improvement plans are analyzed, implemented and reported to leadership.
- Collaborates with Occupational/Employee Health to institute measures to protect and prevent healthcare workers from injuries due to communicable diseases. Collaborates with Facility Services to ensure an integrated Environment of Care program. Keeps abreast of current scientific literature, recommendations, guidelines, and regulatory requirements which may impact the Infection Prevention Program. Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees.


Qualifications:

Basic Qualifications:
- Master's Degree required in Nursing, Epidemiology, Microbiology, Public Health or other discipline. Valid California license to practice Nursing or certification to practice in another healthcare discipline (ie. clinical laboratory science). Current Certification in Infection Control (CIC) required.
- Minimum of five (5) years of infection prevention experience in acute health care facility. 3-5 years progressively more responsible related work experience with 3 years current management experience in assigned service area preferred; or completion of management training program required. Demonstrated leadership skills. Demonstrated skills in program management, project management, time management, and/or resource management. Demonstrated ability to influence change. Demonstrated skills in collaborative and team work. Demonstrated problem-solving, analytic, and decision making skills. Demonstrated written and oral communication skills. Demonstrated ability to develop and present educational programs. Demonstrated ability to apply adult learning principles. Demonstrated computer software application skills such as Lotus Notes, Words, Excel, and Powerpoint.
]]> Wed, 15 Feb 2012 14:00:00 GMT 2175943-Oakland-Quality-Assurance,-Utilization-Review,-or-Case-Management
This position is also responsible for two key functions: Analytics (building and designing studies that can be published) and Reporting/Programming (going into databases to extract data and create programs that generate data for studies).

Essential Functions:
- Leads a complex, highly skilled group of managers that oversee statisticians, analysts, consultants, and programmers as a primary resource, expert consultants to senior leadership and staff major and complex program wide health initiatives with strategic importance to KP (e.g., KP HealthConnect Oncology evaluation study and The Joint Commission regulatory data abstraction automation)
- Provides leadership and management to Analytics & Evaluation group responsible for creating new knowledge on the impact of KP HC and kp.org on Quality of care, Member service, and Affordability
- Provides leadership and management to Knowledge Mgmt and Consulting group responsible for sharing, documenting and disseminating best KP HC / kp.org practices across regions to operations leaders
- Provides leadership and management to Care Reporting and Consulting group responsible for providing new views and insights on quality / patient safety / service reporting on coding / extraction from complex databases in KP HealthConnect, kp.org and other KP databases.This area also provides leadership for data architecture and data infrastructure in partnership with IT.
- Is part of the leadership team for HIT (Health Information Technology) Transformation and Analysis and National Quality and Care Delivery Excellence organizations.

Qualifications:

Basic Qualifications:
-Minimum of 10years in health care industry, seven of which in health care consulting, strategy, planning and project management.
- Demonstrated ability to determine the key business issues and develop appropriate action plans from multidisciplinary perspectives.
- Substantial knowledge in one or more of the following: quantitative analysis, financial analysis, information systems, organization development, decision science, operations research, health care delivery systems, or project management.
- Demonstrated ability to lead professionals through influence and collaboration.
- Proficient in team building, critical thinking, conflict resolution, group interaction, project management, and budget management.
- Demonstrated ability to define the strategy of and provide overall direction to a specified practice area.
- Excellent skills in complex analytic problem solving, planning, project management, change management, and group process.
- Excellent communication skills - both written and oral appropriately gauged to a broad range of audiences from the most senior of KP leadership to front-line physicians and staff to peers in various disciplines.
- Understanding of KP operations and competitors, and economic, social, and legal environment. Must be able to work in a Labor/Management Partnership environment.
- Master's degree or equivalent experience in Business Administration, Economics, Health Care Administration, Operations Research, Public Health Administration, Biostatistics or other related field. PhD a plus.

Preferred Qualifications:
- Green belt or Black belt in performance improvement preferred
- KP experience in working with senior leaders and consulting
- KP experience with care delivery operations
- KP experience with KP HealthConnect and or kp.org
- KP experience in data extraction
- KP experience in advanced analytics and research
- KP experience in project management and performance improvement]]> Mon, 30 Jan 2012 14:00:00 GMT 2134516-Oakland-Quality-Assurance,-Utilization-Review,-or-Case-Management Essential Functions:
- Oversees the development, design, & coordination of Service Area (SA) wide Medical Staff Office in collaboration w/ Chiefs of the appropriate functions
- Coordinates respective accreditation surveys (NCQA, CALS/The Joint Commission) & ensures compliance w/ regulatory agency standards
- Develops, implements, monitors, & revises policies & procedures for the Office of Medical Staff Services
- Coordinates link between medical staff affairs, quality improvement, risk management, & continuing medical staff education based on outcomes
- Manages day-to- day activities of the Medical Staff Office functions throughout the SA, including coaching, counseling, disciplinary actions, & budgeting
- Periodically meets w/ the Quality Leader to review activities at the medical centers & medical office buildings & to discuss policy recommendations for approval
- Supports Executive Committee(s), including agenda preparation, minutes, & follow-up


Qualifications:

Basic Qualifications:
- Significant experience (4+ years) in a hospital setting with a minimum of 2 years supervisory experience required
- Experience in word processing, MIDAS, and data base management
- Experience with medical staff functions
- Previous experience w/ CALS accreditation survey process
- Bachelor's degree in Health Science or equivalent experience preferred
- CPCS (Certified Provider Credentialing Specialist) and/or CPMSM (Certified Professional Medical Services Management), preferred
- Participation in NCQA and The Joint Commission accreditation process
- Training in principles and tools of TQM/CQI
- Knowledge of credentialing and privileging
- Excellent written, verbal communication, organizational, and strong interpersonal skills required
- Must be able to work in a Labor/Management Partnership environment
]]> Sun, 18 Sep 2011 16:00:00 GMT 1414117-San-Francisco-Quality-Assurance,-Utilization-Review,-or-Case-Management