Job Summary: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 Permanentes Code of Conduct by adhering to federal, state, local laws and regulations, accreditation licensure requirements and Kaiser Permanentes policies and procedures.Essential Responsibilities:
- Reviews UM required written notices based on members jurisdiction and product line following regulatory requirements and UM policies and procedures.
- 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 assigned.
Basic Qualifications:Experience
- Two (2) years of utilization review experience required.
- Two (2) years of clinical experience required.
- Two (2) years of experience working with computer system applications required to navigate windows-based computer program; familiarity with windows accessories/tools such as edit, search, copy/paste, find and help and comfort level with internal searches and use of web tools for support.
Education
- Bachelors degree in nursing required.
License, Certification, Registration
- This job requires credentials from multiple states. Credentials from the primary work state are required before hire. Additional Credentials from the secondary work state(s) are required post hire.
- Registered Nurse License (Virginia) within 6 months of hire AND Registered Nurse License (Maryland) within 6 months of hire
OR
- Compact License: Registered Nurse within 6 months of hire
- Registered Nurse License (District of Columbia) within 6 months of hire
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.
- Masters degree preferred.
- Prior Experience with Denial Letter Processing Preferred