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, analytical person, and negotiator to achieve resolution on member requests, appeals and issues with contracted providers. Responsible for reviewing and analyzing audit related reports and providing consultation on non-compliance. Manages the planni... more details
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, analytical person, and negotiator to achieve resolution on member requests, appeals and issues with contracted providers. Responsible for reviewing and analyzing audit related reports and providing consultation on non-compliance. Manages the planning, development, implementation/delivery, and evaluation/ improvement of rehabilitation therapy programs/services provided by extended care contracted providers.
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.
Works directly with all levels of Home Care Service clinical and administrative leadership to identify and address gaps in knowledge, process, and systems as they affect clinical, quality and compliance outcomes.
Identifies gaps in 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, analytical person, and project manager to close clinical, quality, educational and compliance gaps.
Reviews member complaints to identify potential quality issues and address as indicated. Develops resources and implements solutions for all levels of Home Care staff. Ensures action plans are conducted, tracked, and completed.
Provides direct support and consultation on corrective actions developed by departments for areas of non-compliance to ensure the compliance issue(s) is addressed.
Assists in the development of appropriate policies relating to compliance, clinical and quality.
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 Care at Home department and organization.
Produces or oversees development of written materials for various peer groups, functional staff, and high-level audiences. Plans and facilitates meetings.
Makes formal presentations to various audiences as pertinent to Home Care Services.
Works with KFHP/KFH, Medical Group departments and Senior Leadership at the regional, and local levels as consultant on policy and procedures, rollouts, etc.
Coordinates the audit process, including reviewing, analyzing, and reporting findings internally to the appropriate service line leadership locally or at the service line office level, including leadership/quality committees.
Leads, makes significant contributions, and/or provides technical leadership to high visibility projects to identify and resolve issues of strategic importance to the organization.
Interfaces regularly with senior management to produce timely and valuable results.
Other service line duties as required.
Basic Qualifications:
Experience
Minimum five (5) years of clinical rehabilitation therapy experience.
Education
Graduation from an accredited physical or occupational therapy educational program with a masters degree in physical or occupational therapy required.
License, Certification, Registration
Physical Therapist License (California) OR Occupational Therapist License (California)
Additional Requirements:
Personal transportation required for local Service Area travel (SCAL).
May require some travel to the Service Areas across SCAL and/or regional offices
Excellent interpersonal, verbal, and written communication skills.
Demonstrated conflict resolution and mediation skills with ability to secure action from persons outside their supervision. Ability to collaborate with peers in self-managed teams to meet deadlines.
Ability to use sound judgment and to manage 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 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.
Preferred Qualifications:
Previous Supervisory or Management experience.
Clinical rehab therapy experience in Home Health, Hospice or Home-Based Palliative Care.
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