Nurse Consultant PICU

Description: Job Summary:

Provides/gathers clinical expertise for areas of compliance which involve medical necessity and/or quality concerns. Utilizes clinical expertise to conduct investigations and seek input from other clinical professionals as required. Acts as a liaison, problem-solver, and negotiator to achieve resolution on member requests and appeals. Responsible for reviewing and analyzing audit related reports and providing consultation on non-compliance.

Essential Responsibilities:

• Works directly with Member Services organization and other clinical and administrative leadership to investigate and facilitate resolution of complex and high profile member requests and appeals. Provides/gathers clinical expertise for areas of compliance which involve medical necessity and/or quality concerns. Interprets clinical cases (grievances and appeals including lab values, medical records and interpretation) and presents appropriate clinical material for Physician review. Reviews member complaints to identify potential quality issues that should be referred to the local Quality Departments. Provides direct support and consultation on corrective actions developed by departments for areas of non-compliance to ensure the compliance issue(s) is adequately addressed. Utilizes clinical expertise to conduct investigations and seek input from other clinical professionals as required. Acts as a liaison, problem-solver, and negotiator to achieve resolution on member requests and appeals. Leads and/or represents Regulatory Compliance at routine and ad hoc meetings on specific compliance areas relating to DMHC regulations. Maintains database and provides all user groups timely notice of updates and implementation timeframes according to the regulations. Works with KFHP/KFH, Medical Group departments and Senior Leadership at divisional, regional, and local levels as consultant on Department of Managed Health Care (DMHC), Center of Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and Department of Health Services (DHS) compliance and develops, implements, tracks, and reports on work plans for correction. Participates in the development and implementation of internal audits for DMHC, CMS, NCQA, DHS, and State Programs compliance. Coordinates the audit process, including reviewing, analyzing, and reporting findings internally to the Director, Senior Leadership, and to KFHP quality committees. Assists in the development of appropriate policies relating to compliance. Participates in the development and implementation of necessary educational programs to ensure all appropriate parties are knowledgeable about their compliance responsibilities on an on-going basis. Leads, makes significant contributions, and/or provides technical leadership to high visibility projects to identify and resolve issues of strategic importance to the Standard Unit, Correspondence Center unit and organization. Interfaces regularly with senior management to produce timely and valuable results. Produces or oversees development of written materials for various peer groups and high-level audiences. Plans and facilitates meetings. Makes formal presentations to various high-level audiences.

Basic Qualifications:

Experience

Minimum 5 years experience and knowledge in subject matter area of expertise. Excellent interpersonal, verbal and written communication skills. Ability to work with peers in self-managed teams to meet deadlines. Demonstrated conflict resolution and mediation skills with ability to secure action from persons outside their supervision. Ability to use sound judgment and to handle potentially charged issues independently but with the knowledge and ability to escalate and ask for help when needed. Ability to multi-task and manage time in order to perform well on long-term projects while being flexible enough to assimilate short term projects on an on-going basis. Able to work in a Labor / Management Partnership environment. May require some travel to the Service Areas and/or Regional offices across the Division. Personal transportation required for local Service Area travel

Education

• BSN or BA in health related field preferred. Graduate of accredited school of nursing required. Current California RN license required. Registered Nurse Degree required.

License, Certification, Registration

• Registered Nurse License (California)

Additional Requirements:

Preferred Qualifications:

• Registered Nurse Degree

Notes:

• Must have Pediatric ICU experience
• Quality and Data Abstraction and Interpretation experience
• Virtual Pediatric ICU System experience

Primary Location: California,Los Angeles,Los Angeles Medical Center
Scheduled Weekly Hours: 40
Shift: Day
Workdays: Mon, Tue, Wed, Thu, Fri
Working Hours Start: 08:00 AM
Working Hours End: 04:30 PM
Job Schedule: Full-time
Job Type: Standard
Worker Location: Onsite
Employee Status: Regular
Employee Group/Union Affiliation: NUE-SCAL-01|NUE|Non Union Employee
Job Level: Individual Contributor
Department: Sunset Medical Center - ICU- Pediatrics - 0801
Pay Range: $64.56 - $83.5 / hour 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
On-site: Work location is on-site (KP designated office, medical office building or hospital). 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.

For jobs where work will be performed in unincorporated LA County, the employer provides the following statement in accordance with the Los Angeles County Fair Chance Ordinance. Criminal history may have a direct, adverse, and negative relationship on the following job duties, potentially resulting in the withdrawal of the conditional offer of employment:

Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state, and local laws and regulations, accreditation, and licensure requirements (where applicable), and Kaiser Permanente's policies and procedures.

Models and reinforces ethical behavior in self and others in accordance with the Principles of Responsibility, adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty, shows consistency in words and actions; follows through on commitments.

Job duties with at least occasional or possible access to: (1) patients, the general public, or other employees; (2) confidential protected health information and other confidential KP information (including employee, proprietary, financial or trade secret information); (3) KP property and assets, for example, electronic assets, medical instruments, or devices; (4) controlled substances regulated by federal law or potentially subject to diversion.

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