Kaiser Permanente - Los Angeles Quality Assurance, Utilization Review, Or Case Management jobs

Credentialling Specialist - (Pasadena, California)

Sat, 15 Jun 2013 16:00:00 GMT

Req Id: 171052

Responsible for reviewing & auditing credentialing practices & processes standards; credentials & insures that all documents for providers/facilities are current. Develops & recommends action plans for facilities & Medical Staff Offices not meeting KP credentialing standards. Provides consultation & educational services, Permanente & at external contracted offices.
Essential Functions:
- Audits credential files to insure compliance w/ regulatory & KP specific credentialing criteria & standards at all regional medical staff offices & regional credentialing
- Performs site visits at contracted facilities, audits files, & established procedures & processes to insure compliance w/ credentialing standards & regulations
- Prepares reports reflecting audit findings for submission to regional Credentialing & Privileging Committee & senior management detailing the compliance w/ KP credentialing standards; develops & recommends for adoption action plans for facilities and/or medical staff offices not meeting KPr's credentialing standards
- Responsible for maintaining & updating delegation agreements w/ non-KP facilities & other credentialing related files
- Provides consulting services to medical staff offices on credentialing standards & processes in complaince w/ regional policies & develops & conducts individual & group inservice training related to credentialing standards, regulations, & regianal policies
- Partners w/ medical staff office staff & appropriate hospital & medical group individuals to implement systems & processes that meet regulatory standards & regional credentialing policies & procedures
- Keeps abreast of changes in laws & regulatory requirements
- Implements internal processes & communication mechanisms that support organizational strategies & regional credentialing objectives
- Perfoms quality oversight of the credentialing process at assigned medical staff offices & at outside facilities
- Asists in preparations for regulatory surveys & audits by compiling data & reviewing files & other credentialing data to insure compliance w/ relevant standards

Qualifications:

Basic Qualifications:
- Three (3) - five (5) years of experience related to credentialing or accreditation in a hospital or ambulatory setting
- AA degree OR equivalent experience
- Bachelor's degree preferred
- Proficient in medical terminology
- Thorough knowledge of Federal, State, and certifying agencies regulatory requirements and accreditation standards, e.g., TJC, Title XXII, NCQA, NPDB
- Strong organization, written and communication skills: attention to detail required
- Ability to lead and facilitate processes through influence and collaboration
- Demonstrated problem-solving skills and initiative
- Service oriented and the ability to work in a team environment required
- Demonstrated ability to audit practitioner and provider credentialing files for accuracy and compliance with all regional, state and federal regulations
- Additional Skills: Proficient with PC, Word, Excel, Access, Lotus/Outlook
- Position requires travel throughout Southern California; must possess a valid California driver's license

Managing Director Health Plan Quality \ Regulatory Oversight - (Pasadena, California)

Thu, 06 Jun 2013 16:00:00 GMT

Req Id: 167689

Under the direction of the Southern California Executive Director for Quality & Risk Management, the Managing Director for Health Plan Quality & Regulatory Oversight is responsible for:
The oversight of development, planning, management, and integration of Southern California KFH/HP organizational programs related to:
Quality Operations, Behavioral Health Regulatory Oversight, Accreditation, Regulations and Licensing areas, emerging Regulations/Legislations. This position will lead highly visible, complex and politically risky improvement projects that are of strategic importance to the company. This position will oversee the development and execution of action plans/deliverables. This position will also oversee, design, support and lead any necessary communication and governance/oversight mechanisms required. This position is responsible for building relationships and ongoing interaction with facility quality leaders and Senior Leaders to ensure the direction of the departments, functional areas, programs and initiatives are in alignment with organization-wide goals and priorities. Ensures consistency of operational system processes and standards according to the region's strategic business plan related to quality.
Identifies and institutes enhanced quality practices based on benchmarking with other industries and internal practice transfer.
Facilitates the rapid transfer of best practices across geographical boundaries. Participates in state networks and provides a presence to highlight the organization's leadership and innovation in the health care industry. Recommends adjustment to operations to meet changing business and market conditions, and ensure continued high levels of performance with regulatory and accreditation requirements.
Employs effective change management techniques.

Essential Functions:
- Provides operational leadership and consultation to Southern California executive management, SCPMG, and Southern California service areas on clinical, regulatory, service, quality and utilization management related practices across the continuum of care. Identifies and institutes enhanced quality practices based on evidence based outcomes and industry standards.
- Provide leadership and expert consultation on the design, development, and implementation of programs related to the expertise area. While providing overall strategic direction for complex projects may also assume the role as the manager of one or more technical units.
- Provides for the development, implementation, and evaluation of effective clinical and service quality programs, policies, standards, practices, and procedures consistent with organizational objectives and the KP Promise.
- Partners with and has accountability with risk management, patient safety and quality leadership, SCPMG, and Patient Care Services to produce improved quality outcomes in the hospitals.
- Expertise in federal/state regulations and accrediting agency standards and works in collaboration with Medical Centers and Regional departments to ensure compliance to various regulatory surveys. Responsible for providing oversight to quality, accreditation and licensing at each medical center through awareness of local processes and coordination of updates to Regional Quality Committee.
- Directs and coordinates with Program Office and KP regions for quality functions.
- Accountable to achieve outcomes related to improving quality of care and service.
- Hires, performs disciplinary actions, provides employee training/development, and conducts performance assessments.
- Develops and monitors the payroll, non-payroll, and capital budgets for assigned areas of responsibility.

Qualifications:

Basic Qualifications:
- Clinical and operations background required.
- Departmental management experience required.
- Extensive experience, typically ten years or more years, in a leadership role for a multi-faceted health care system.
- Master's degree in Business, Health Care, Public Administration or related field.
- Proven ability to develop quality standards, policies, processes that impact multiple groups.
- Effective and superior verbal and written communication skills, facilitation skills, and presentation skills required.
- Demonstrated critical thinking, influencing, problem solving, and analytical skills required.
- Excellent leadership and strategic thinking skills and the ability to drive business results by motivating staff.
- Knowledge of the contemporary issues in the areas of quality management with demonstrated results addressing these issues. Decisiveness, action-orientation, personal integrity, capability to persevere in difficult situations and a focus on strategic leadership issues required.
- Incumbent should also possess an open, collaborative leadership style that promotes teamwork and partnership while achieving desired results.
- Demonstrated ability to lead professionals through influence and collaboration.
- Proficient in team building, conflict resolution, change leadership, systems thinking, group interaction, results orientation and budget management.
- Demonstrated knowledge of the intricacies of hospital/HMO/medical office operations and practices.
- Proven leadership skills in complex analytic problem solving, project management and consulting especially on highly visible, politically sensitive issues, change management, and group process. Understanding of KP operations and competitors, and economic, social, and legal environment.
- Advanced knowledge of computer applications and knowledge of data systems required.
- Must be able to work in a Labor/Management Partnership environment.
- Demonstrated ability to determine the key business issues and develop appropriate action plans from multidisciplinary perspectives.
- Must demonstrate an understanding of health policy trends and any applicable regulations related to the responsible technical area.

Preferred Qualifications:
- CPHQ preferred.
- Established track record with Kaiser Permanente preferred, particularly in working across geographic and entity boundaries and with multidisciplinary teams.

National Transplant Services Hub Operations Manager Los Angeles CA - (Los Angeles, California)

Wed, 17 Apr 2013 16:00:00 GMT

Req Id: 176720

National Transplant Services Hub Operations Manager
Los Angeles, CA

These positions demonstrate in-depth knowledge and skills and are accountable to manage strategic projects, the quality program and care coordination operations that are aligned with the goals of National Transplant Services. The roles function as expert authority for KP transplant management across the program and all regions ensuring consistent operations oversight, application and implementation of NTS and regional policies, successful practices, and technology support. The senior positions share in accountability of outcomes and performance improvement for the Program's transplant population.
Essential Functions:
- Assists the Senior Mgr, Director, or Executive Director in developing and executing goals that promote the overall success of the NTS.
- Provides primary oversight and responsibility of day to day operations of one of the NTS transplant hubs (NCAL, SCAL, CE) to include: daily delivery of case management activities, coordination of referrals, monitoring and concurrent review of inpatient stays and reporting of quality event/issues.
- Supervises staff in one NTS hub.
- Facilitates problem resolution for patient related issues including: cross departmental collaboration and support; Investigates and resolves patient/family/ member concerns regarding care received within Plan and at contracted COEs.
- Supports the Sr. Manager or Director in determining service priorities, staffing and workforce resources, and workflow requirements and implements plans with approved resources.
- Establishes effective working relationships with peers both internal to KP and external for resolving individual patient /member issues.
- Participates in development of Department's Performance Improvement.
- Impacts the achievement of functional and departmental goals.
- Failure to identify barriers and achieve results may cause delays in achieving department's goals and/or require additional resources.
- Involves interpreting and analyzing established administrative concepts.
- Judgment is required to make decisions for less defined issues
- Judgment is required on when to escalate barriers to individual patient problem resolution and achievement of department goals and objectives.
- Works on issues where analysis of situation or data requires review of relevant factors.
- Follows operational policies in selecting methods to determine best solution.
- Problem-solving may involve a variety of sources.
- Interaction requires the ability to gain cooperation of others both internal to KP and with individuals external to KP in care delivery.
- Provides professional and transplant guidance and influences others at both a staff and management level.
- Exercises judgment in evaluating issues, researching options and determining and/or recommending solution.
- Work is reviewed by manager at key intervals for advice and guidance prior to completion for any unusual patient issue or project undertaken.
- Provides formal supervisory (hire, fire, performance management) responsibility for an NTS Hub.
- Provides direction to employees following guidelines, procedures, and policies.

Qualifications:

Basic Qualifications:
- Minimum of 5 years of experience in areas of nursing practice including acute/critical care, case management and/or ambulatory care.
- Knowledge of large complex organization
- Knowledge of nursing practice act, TJC standards, NCQA standards and other regulatory requirements.
- Knowledge of case and utilization management processes and scope.
- Strong interpersonal and communication skills.
- Produces and oversees high quality written materials and presentations
- Bachelor's degree in Nursing.
- Current RN license in state of primary work location (CA, MD), CPR certification (SCAL hub only)
Preferred Qualifications:
- Experience in transplant and/or management in another healthcare / clinical related field preferred.
- Knowledge of transplant workflow or clinical needs preferred.

Director of Utilization Management - (Los Angeles, California)

Thu, 04 Apr 2013 16:00:00 GMT

Req Id: 177295

Develops, manages, & directs the Utilization Management programs in a Service Area or a Medical Center. Develops & manages programs that emphasize appropriate admissions as well as concurrent & retrospective review of care. May also be responsible for other integrated functions such as Discharge Planning, Case Management program, Outside Utilization Review program, Transportation coordination & Extended Care Coordination to promote a centralized, coordinated, interdisciplinary process in the continuum of care.
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, TJC, 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; TJC, 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