QA \ UR \ Case Management Jobs


Correspondence Compliance Coordinator RN UM Short Hours Regional Office Rockville, MD


The Correspondence Compliance Coordinator is responsible for the generation of UM required written notices to Kaiser Permanente members and providers. This position consistently supports compliance and Kaiser Permanente's Code of Conduct by adhering to federal, state, local laws and regulations, accreditation licensure requirements and Kaiser Permanente's policies and procedures.

Essential Functions:
- Reviews UM required written notices based on member's jurisdiction and product line following regulatory requirements and UM policies and procedures.
- Responsible for:
- Verifying correct jurisdiction and product line;
- Coverage and eligibility determination;
- Reviewing documentation to support the written notice to include review of clinical documentation by the appropriate professional;
- Communicating with UM physicians and staff regarding UM required written notice;
- Writing complete and accurate UM required written notices to members, providers and practitioners in easily understandable language meeting all regulatory and accreditation;
- Timely written notice generation, distribution and notification to all parties.
- Validating accuracy of UM decision for final classification (medical necessity, coverage, administrative and others).
- Identifies educational needs related to UM processes, documentation requirements and application of nationally and internally developed UM guidelines.
- Collaborates with the UM Compliance Team to address on-going educational needs related to written notice management.
- Performs other related duties as directed.


Basic Qualifications:
- Two (2) years of utilization review experience required.
- Two (2) years of clinical experience required.
- Two (2) years of experience workingwith computer system applications required.
- Bachelor's degree OR four (4) years of directly related utilization review experience required.
- High School Diploma or General Education Development (GED) required.
License, Certification, Registration
- Current RN licensure in the District of Columbia, Maryland, Virginia (or a Compact State) required.

Additional Requirements:
- Extensive knowledge of NCQA, Medicare and state regulatory UM denial requirements.
- Proficiency in the use of applicable computer software.

Preferred Qualifications:
- Knowledge of managed care preferred.
- Recent acute care, case management, or home health experience preferred.
- Demonstrated ability to effectively and clearly present information through the written word, to influence or persuade others through oral presentation in positive or negative circumstances, and to listen well.
- Demonstrated ability to write clearly, legibly, and effectively, to present ideas and document activities, to read and interpret written information.

Primary Location: Maryland,Rockville,Rockville Regional Offices 2101 E. Jefferson St.

Scheduled Hours (1-40): 16

Shift: Day

Working Days: Mon, Tue, Wed, Thu, Fri, Sat, Sun

Schedule: Short Hour

Job Type: Standard

Employee Status: Regular

Employee Group: UFCW - Local 400

Job Level: Individual Contributor

Job: QA / UR / Case Management

Public Department Name: Utilization Management

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.

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