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 situation 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. • 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.