Emergency Prospective Review Program Nurse Coordinator
Company: Kaiser
Location: South Gate
Posted on: March 13, 2023
Job Description:
Job Summary:
To provide a centrally located and operated initiative for Kaiser
Permanente (KP) Southern and Northern California Regions designed
to help control emergency claims costs and maintain or improve
quality of emergency care received by Health Plan members at non
-Kaiser Permanente facilities nationwide. Will review for
appropriateness situations, where a Health Plan member is receiving
care in an emergency medical situations from community providers
(in area and out of area). Will be using emergency
medicine/critical care clinical experience and general guidelines,
to determine whether to conditionally approve or deny care by
community providers or whether to negotiate for lower level of care
for the member or whether to refer to the SCPMG/TPMG MD on duty for
review or whether to arrange transfer for medically stable members
to a Kaiser Permanente Facility or Kaiser Permanente Contract
Facilities.
Essential Responsibilities:
- Prospective utilization review activities by reviewing cases
with community emergency physicians and making decisions to
conditionally approve or deny treatment and /or transfer Health
Plan members with emergency needs.
- Also direct and assist members appropriately requiring urgent
care level of medical needs.
- Encouraging limited patient work-up where practical to reduce
out-of-plan expenditures and acting as a resource for the Claims
Administration Department.
- Arrange critical care transport of critically
ill/hemodynamically stable Health Plan members from community
facilities (in area and out of area) to Kaiser Permanente
Facilities for the Southern and Northern California Divisions.
- Assess available information and make quick
appropriate/effective decisions regarding level of care required
for Southern and Northern California Health Plan members.
- Notification to Couc /Outside Utilization Coordinators
(Southern California Division) /Case Managers (Northern California
Division) regarding non plan admissions of Health Plan members for
medical issues/situations.
- Assist in the development and implementation of policies and
procedures for the EPRP/Critical Care Transport Program.
- Identify and report to the EPRP Quality Assurance Coordinator
for submission to the Southern and Northern California Divisions KP
facility QA/Risk Management Coordinators regarding quality and risk
management issues to effect favorable management of members thereby
increasing member satisfaction.
- Document interactions and identify emergency medical claims to
assure follow-through for the Claims Administration Department
personnel for the Southern and Northern California Divisions.
- Assist as a liaison with all three Kaiser Permanente entities,
KP contract providers and external providers to help ensure that
members with high cost claims receive timely, coordinated, high
quality and cost effective care. Basic Qualifications:
Experience
- Two (2) years of nursing experience in Emergency Care/Critical
Care required.
Education
- N/A
License, Certification, Registration
- Registered Nurse License (California)
Additional Requirements:
- Knowledge of computers, ability to utilize various software as
required.
- Excellent written and verbal skills.
- Demonstrated ability to communicate effectively in an
understandable manner telephonically and in writing.
- Demonstrated ability in planning, organizing, conflict
resolution, negotiating and interpersonal skills.
- Autonomous professional with minimal need for direct
supervision.
Preferred Qualifications:
- One (1) year of Pediatric or Pediatric Critical Care experience
or one (1) year of Level III Neontatal Critical Care
experience.
- Bachelor's degree in nursing or healthcare related field
preferred.
Notes:
- May rotate to two additional assignments in ETAP and PTAC.
- No schedule template during weekdays, every other weekend
off
Job Schedule:
Job Category: Nursing Licensed & Nurse Practitioners
Keywords: Kaiser, South Gate , Emergency Prospective Review Program Nurse Coordinator, Healthcare , South Gate, California
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