AddressThe Nurse Consultant will provide/gather 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. Reports to the Director of Risk Management, while working collaboratively with Quality and Patient Safety Teams.
Essential Responsibilities:
- Works directly with KPGA Risk Management, KPGA Member Services, and Shared Service Member Services organizations 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.
- Drafts Quality of Care letters to contracted facilities and tracks responses. 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 GA state 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 a consultant with Center of Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and GA Department of Public Health (GADPH) compliance and develops, implements, tracks, and reports on work plans for correction.
- Participates in the development and implementation of internal audits for CMS, NCQA, GADPH, 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 management and KPGA Operations Leaders to produce timely and valuable results.
- Plans and facilitates meetings, as directed. Makes formal presentations to various high-level audiences.
