Washington Permanente Medical Group (WPMG) is a clinician-led, self-governed and independent multi-specialty group practice, providing care to the more than 700,000 Kaiser Permanente patients in Washington state. We work unencumbered by traditional health care obstacles and without silos; prioritizing people over profits, collaboration over ego, and driven by a singular goal: our patients' health. At WPMG, we take care of the whole person, with a team to address the fundamental, social, and emotional needs that contribute to total health. We are clinicians motivated by the desire to make a purposeful difference in the communities we serve, and in how health care is delivered.
Kaiser Permanente-Washington Permanente Medical Group- is seeking a Full Time 1.0 FTE Manager, Referral and Review Services to join our WPMG HQ team in Renton, Washington.
Provides leadership and direction for Review Services Clinical Review teams. Directs the daily operations of utilization review, pre and post service medical necessity review, code review and fraud, waste and abuse case review. Ensures appropriate staffing levels to accomplish established regulatory parameters, customer service, quality and productivity goals. Ensures that authorization requests sent to Prior Authorization and identified as post service claims are reviewed according to appropriate regulatory, coverage and clinical criteria guidelines. Ensures reviews are done in accordance with state, federal, NCQA and CMS guidelines for medical necessity review. Represents clinical review functions during external surveys. Provides advice and consultation within Kaiser Permanente regarding review functions and processes. Manages staff performance by using performance management tools and providing effective coaching and mentoring. Manages department workloads using daily management systems. Partners with Health Plan Sr Mgr for budget responsibility for the accounting unit. Provides appropriate tools and training to staff and provides timely feedback and documentation through staff meetings and one-on-one meetings. Takes appropriate disciplinary action including counseling, performance improvement plans, etc. Responsible for hiring and personnel management. Responsible for delivering on cost savings initiatives which include external delivery system targets and initiatives.
Principal Duties and Responsibilities
The primary job duties this position is responsible for achieving are listed in order of importance.
Participates in the planning, implementation, evaluation and continual improvement of clinical review services to respond to customer expectations and meet KP goals and objectives. Problem solves & develops systems to meet external & internal customer expectations recognizing all regulatory requirements. Applies content and system expertise to leverage services in a collaborative setting with Kaiser Permanente partners and external customers. Supports organizational goals and actively participates in planning events when appropriate. In collaboration with HP leadership teams, identifies strategies to ensure all HP programs and services meet the financial, regulatory, service and quality standards.
Plans, identifies outcomes and implements improvement plans using PDCA processes. Ensures all staff follow standard work that is designed for efficient processing and recognizes regulatory requirements. In collaboration with health plan leadership, identifies and develops standards of practice and contributes to the development and maintenance of medical necessity criteria. Tracks, trends and monitors outcomes standards related to service & quality and implements improvement strategies to ensure patient outcomes are addressed. Has intermediate technical understanding and project management skills for system implementations.
Leads, manages and develops staff to ensure the best use of human resources and to achieve financial, service and quality outcomes. Recruits, hires, promotes, monitors, disciplines and terminates staff when necessary. Completes & presents performance evaluations. Mentors & coaches staff to meet or exceed cost, quality, service and staff satisfaction outcomes. Builds teams & develops individuals to effectively problem solve, resolve conflict and demonstrate appropriate team behavior using basic lean principles and standard PDP tools. Is available to UM Staff either at the physical location, by phone, email, IM or text during staff working hours.
Effectively and efficiently manages resources - staff and budget - to meet financial targets. Develops productivity strategies using demand and cycle times. Makes decisions related to resource allocation and priorities using visual systems and contingency planning for high or low demands. Identifies & participates in the development of ongoing orientation, educational & training programs for the department. Participates in the orientation and training of staff. Measures interrater reliability with appropriate follow-up training and problem-solving. Monitor and update documentation to ensure accuracy.
Responsible for delivering on cost savings initiatives which include external delivery system targets and initiatives.
Knowledge and Skills (required)
Demonstrated leadership skills with the ability to direct the activities of others on a direct or matrix team basis.
Ability to lead, guide and integrate strategic planning processes and organizational goal development.
Ability to supervise and train staff, including organizing, prioritizing and scheduling work assignments. Knowledge of management principles and practices. Employee development and performance management skills.
Ability to collaborate and be influential across structures and roles.
Knowledge of delivery system operations, healthcare delivery systems and trends.
Demonstrated knowledge of industry dynamics in health plan and care delivery organizations including compliance and regulatory requirements.
Skill in examining and re-engineering operations and procedures, formulating policy, and developing and implementing new strategies and procedures.
Knowledge of business process, thorough knowledge of medical terminology, and medical care procedures.
Knowledge of finance, accounting, budgeting and cost control procedures. Strong analytical skills and knowledge of statistical methods.
Proficiency in MS Office
Ability to challenge established ways and lead change.
Demonstrated effective problem solving and decision-making skills.
Proven negotiation and conflict resolution skills.
Renton, with a population of 101,300, is located on the south shore of Lake Washington with spectacular views of the lake, the Olympics, the Cascades, and Mount Rainier. The Cedar River runs through the heart of downtown and offers an abundance of natural beauty and a run of federally endangered chinook salmon. The City is centrally located for access to the regions' transportation network, accessible by four state and three interstate highways, only minutes away from Seattle, Bellevue, Tacoma and Sea-Tac Airport. Renton's strong economic base, diverse marketplace and favorable business climate have attracted the attention of nationally recognized companies that are looking to provide employees and their families with an outstanding quality of life.
We are dedicated to building lifetime relationships with peers and patients in Washington State's richly diverse communities. Many know the Pacific Northwest as an attractive tourist destination with beautiful scenery, friendly people, and a host of cultural and recreational opportunities. These elements, and others, make Washington an excellent place to live.
Equity, Inclusion and Diversity
In our local communities and across the nation, Kaiser Permanente sets the standard for respectful care. With multicultural staff, equity, inclusion and diversity councils, medical interpretation resources, outreach efforts, educational programs and more, Kaiser Permanente puts people first in our medical centers and beyond.
As part of Kaiser Permanente, Washington Permanente Medical Group (WPMG) seeks to create equity in our communities, eliminate health disparities, and always put patients--the heart of everything we do--first.
Following the guidelines in our National Diversity Agenda, every member of our team strives to:
Provide culturally responsive and appropriate medical care to improve the health and satisfaction of all people in our increasingly diverse membership
Recruit and retain clinicians and staff that enhance our workforce
Grow our membership by providing exceptional service and clinical care to all communities in our region
Creating a diverse workforce, an inclusive environment, and equitable opportunity for employment, growth, and advancement are deeply linked to our mission, our business, and our economic future. WPMG continues to add programs that build and maintain a workplace where we engage with our members, communities, and each other--with dignity, respect, and cultural understanding.
Equal Employment Opportunity
As part of our commitment to our employees and the members and patients we serve, we integrate diversity into all aspects of our operations. Maintaining a workforce with industry-leading levels of diversity through deliberate planning, development, and outreach is critical to fulfilling our mission, sustaining our business objectives, and providing the best level of care to our members and patients. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.