Job Description

Job Summary:

The Auditor will be auditing clinical criteria reviews to ensure correct level of care and educating utilization management staff across the Continuum of Care.

Essential Responsibilities:

• Monitors/Audits UM nurses criteria reviews to ensure referral integrity is maintained and to ensure adherence to MCG guidelines. Provides immediate feedback to both employee and manager. Conducts timely and consistent coaching/monitoring with a goal of instilling and maintaining confidence and empowerment while identifying areas in need of improvement.


• Analyzes and communicates with UM Management team regarding patterns and trends in performance and maintains systems for ensuring follow-up. Identifies resources and techniques that would assist in quality improvement. Defines individual and team needs to improve and recognize competencies and to relay non-restrictive flow of information.


• Keeps informed of all changes to MCG guidelines, workflows, system enhancements and regulations, which could affect the criteria review and referral process. Improves efficiencies and employee satisfaction through effective partner tools and resources.


• Provides ongoing training/education utilizing MCG modules, MCG case studies and other methods deemed appropriate to enhance the teams understanding of MCG and improve the quality of criteria reviews completed.


• Identifies areas for workflow improvement and provide solutions to streamline processes.


• Reports weekly results of audits to the UM managers and UM director. The individual in this position will be required to maintain proficiency in KPHC and stays current with updates impacting workflow. Auditors must be able to coach on an individual basis and lead small group learning and development sessions addressing components of referral integrity.


• Perform daily adits on patient referrals completed by the UM (PCC) nurse team. Utilize standardized auditing tool daily. Identify training needs based on trends and deficits noted in the audit proces. Outreach to the Lead PCC in each region and managers to provide feedback on  criteria reviews and referral integrity.


• Acts as subject matter expert and resource for clinical teams related to referral integrity. Responds to questions/concerns from the teams and supervisors respective to utilization review and management. Escalates issues as appropriate to the manager or UM Director. Conduct targeted audits of new hires and individuals consistently not meeting quality standards, provide input to the managers/director for improvement plans. Maintains adequate production, quality, and timeliness of audits, as defined by the position.


• Real Time Historical Data: Identifies variances and trends, makes recommendations for improvements to enhance referral integrity/quality.


• Input to Improve Quality: Works with leadership team to identify process, system and training needs to achieve improved accurate and efficient referral management. Works with PCC regional leads and manager for one-on-one and small group training. Document all one-on-one education, training and remdiation done. Work as a liaison between the PCC team and UM leaders to identify and resolve barriers to accurate information concerning criteria reviews and referral integrity.


• Reporting/Documentation: Produces weekly audit summary reports to analyze audit findings and trends; Identify areas of targeted training. Work with leadership team to train, mentor and remediate the PCC team, as indicated.

M-F, Every Third Weekend Rotation

Basic Qualifications:

Experience

• Minimum five (5) years of nursing experience.


• Minimum two (2) years of acute utilization management experience.

Education

• BSN or bachelors degree in health care administration, other health related field, OR four (4) years of experience in a directly related field.


• High School Diploma or General Education Development (GED) 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

• Basic Life Support

Additional Requirements:

• Demonstrated strong clinical knowledge base, judgment, and experience.


• Ability to analyze, integrate, and use quantitative data information in making business decisions and problem solving.


• Must be able to work in a Labor Management Partnership environment.

Preferred Qualifications:

• Previously trained as a Quality and/or UM auditor


• ACM or CCM preferred.

Primary Location: Maryland,Hyattsville,New Carrollton Administration Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri, Sat, Sun Working Hours Start: 08:30 AM Working Hours End: 05:00 PM Job Schedule: Full-time Job Type: Standard Worker Location: Remote Employee Status: Regular Employee Group/Union Affiliation: NUE-MAS-01|NUE|Non Union Employee Job Level: Individual Contributor Department: Regional Office - UR-Discharge Planning - 1808 Pay Range: $98700 - $127710 / year Kaiser Permanente strives to offer a market competitive total rewards package and is committed to pay equity and transparency. The posted pay range is based on possible base salaries for the role and does not reflect the full value of our total rewards package. Actual base pay determined at offer will be based on labor market data and a candidate's years of relevant work experience, education, certifications, skills, and geographic location. Travel: Yes, 10 % of the Time Remote: Work location is the remote workplace (from home) within KP authorized states. Worker location must align with Kaiser Permanente's Authorized States policy. At Kaiser Permanente, equity, inclusion and diversity are inextricably linked to our mission, and we aim to make it a part of everything we do. We know that having a diverse and inclusive workforce makes Kaiser Permanente a better place to receive health care, a more supportive partner in our communities we serve, and a more fulfilling place to work. Working at Kaiser Permanente means that you agree to and abide by our commitment to equity and our expectation that we all work together to create an inclusive work environment focused on a sense of belonging and wellbeing.

Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status. Submit Interest

Job Tags

Remote job, Full time, Work experience placement, Immediate start, Shift work, Weekend work,

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