Utilization Review Nurse Coordinator - Long Term Care at Kaiser Permanente

Kula, Hawaii, United States -

Full Time

Start Date

Immediate

Expiry Date

12 Jun, 26

Salary

0.0

Posted On

14 Mar, 26

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Utilization Review, Long Term Care, Clinical Knowledge, Regulatory Knowledge, Discharge Planning, Medical Necessity, Coordination, Data Analysis, Compliance, Evidence-Based Medicine, Consulting, Relationship Building, Cost Optimization, Quality Assurance, Communication, Team Collaboration

Industry

Medical Practices

Description

Job Summary: In addition to the responsibilities listed below, this position is also responsible for applying advanced clinical and regulatory knowledge of evidence-based guidelines, insurance policies, and clinical criteria to consult on the level of care and duration of treatment required for complex and/or escalated reviews, and providing guidance to team members and collaborating with the health care team, members, and caregivers to assist in discharge planning, cost of care options, and/or coordinating and/or adjudicating referrals to appropriate services based on medical necessity Reports directly to the Hospital Administrator and coordinates with physicians, staff, the interdisciplinary team, regional partners, and non-Kaiser providers and facilities regarding patient care Responsible for evaluating all incoming admission referrals to Kula Hospital to ensure clinical appropriateness, bed availability, and alignment with hospital capabilities. This role serves as a key liaison between referring providers, internal departments, and hospital leadership to facilitate timely, safe, and efficient patient admissions. The coordinator ensures that referrals meet regulatory and operational standards and supports optimal patient flow in a rural critical access hospital setting. Essential Responsibilities: Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional/external stakeholders and customers. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers. Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses; leads by influencing others through technical explanations and examples and provides options and recommendations. Adopts new responsibilities; adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support a business outcome. Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions; encourages team members to adapt to and follow all procedures and policies. Collaborates cross-functionally and/or externally to achieve effective business decisions; provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines. Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions. Provides high-quality consultation by: leading communication efforts with physicians, managers, staff, members, and/or caregivers regarding requirements related to medical necessity and benefit denials across the continuum of care and resolving communication issues within the work team; and leveraging advanced knowledge to ensure the correct and consistent application, interpretation, and utilization of member health care benefits, cost of care options, and coverage by members and physicians. Facilitates education and compliance initiatives by: remaining up-to-date and sharing information with the broader team on the relevant state and federal regulations, guidelines, criteria, and documentation requirements that affect utilization management; and leading the development and delivery of education and training programs for staff and physicians at the local and regional level to promote best practices in utilization management. Facilitates quality improvement efforts by: conducting advanced data analyses and developing reports to identify utilization patterns, trends, and opportunities for improvement; providing input and participating in the implementation of corrective action plans to address deficiencies and evaluate effectiveness in utilization review workflows/processes; actively adhering to utilization policies, procedures, and guidelines to ensure compliant and cost-effective care; and developing, refining, and providing oversight for desk-level procedures (e.g., workflows). Performs utilization reviews by: following standard policies and procedures when conducting reviews of medical records and treatment plans to evaluate the medical necessity, appropriateness, and efficiency of requested healthcare services, and providing support to team members for reviews; and assessing the ongoing need for services, proactively identifying, anticipating, and escalating potential issues/delays to appropriate stakeholders, and recommending appropriate actions for high-risk member cases. Review all admission referrals for clinical appropriateness, payer source, and alignment with hospital services. Collaborate with referring providers, case managers, and internal clinical teams to clarify referral details and determine suitability. Maintain real-time awareness of bed availability, staffing levels, and service capacity and communicate such to internal partners as necessary. Coordinate with the Hospital Administrator and Nursing Leadership to approve or redirect referrals. Document referral decisions and communications in the hospitals EMR (e.g., EPIC) and referral tracking systems. Monitor and report referral trends, acceptance rates, and reasons for denial to support strategic planning. Participate in daily huddles and interdisciplinary rounds to stay informed of hospital census and anticipated discharges. Communicate with Infection Control, Social Work, and other departments as needed to support safe admissions. Ensure compliance with EMTALA, CMS Conditions of Participation, and other regulatory requirements. Support the development and refinement of referral workflows and protocols. Participate in routine Care Without Delay meetings with Acute Hospital partners. Basic Qualifications: Experience Minimum five (5) years of experience in direct patient care, utilization review/management or discharge planning in a managed care setting or a directly related field. Minimum of two (2) years experience in Long Term Care (LTC)/Skilled Nursing Facility (SNF) setting. Education Bachelors degree in Nursing required. License, Certification, Registration Registered Nurse License (Hawaii) required at hire Basic Life Support required at hire Additional Requirements: Knowledge, Skills, and Abilities (KSAs): Medical Terminology; Clinical Learning Solutions; Nursing Principles; Information Gathering; Cost Optimization; Written Communication; Confidentiality; Maintain Files and Records; Acts with Compassion; Consulting; Relationship Building; Coordination; Leverages Technology; Member Service; Quality Assurance and Effectiveness; Evidence-Based Medicine Principles. Preferred Qualifications: Three (3) years of experience in utilization review/management.

Responsibilities

This role involves applying advanced clinical and regulatory knowledge to consult on the level and duration of care for complex reviews, while also serving as a key liaison for timely, safe, and efficient patient admissions to Kula Hospital. Essential duties include performing utilization reviews, ensuring clinical appropriateness, coordinating with the healthcare team, and facilitating education on utilization management best practices.