Under the direction of a licensed provider, performs administrative functions to promotes coordination of care to different acute levels of care within the healthcare delivery system and coordinate emergency care within the scope of defined authority.
Facilitates care of members in under the direction of Kaiser Permanente of the Mid-Atlantic States (KPMAS) staff, Mid-Atlantic Permanente Medical Group (MAPMG), Network, contracted and noncontracted providers.
Is the first and essential point of contact to receive and processes emergency and urgent care notification regarding Kaiser Permanente members in coordination with MAPMG.
Provides technical and administrative support in a professional manner for KPMAS and Hospital Services Management (HSM), Inpatient Behavioral Health offices, and Critical Decision Units (CDUs).
Coordinates health care services for members in affiliated and non-affiliated service delivery systems.
Conducts concurrent review of ER patients and make follow-up appointments as indicated; reserve beds as requested and, arranges ambulance transportation with attention to supporting therapies per guidelines.
Assists with core and non-core facility repatriations to ensure timely, quality care of members and admissions in accordance with policy and procedures.
Processes inpatient admission authorizations, short stay and ER referrals per policy and procedures.
Processes emergency requests for Oxygen and biliblankets after normal UMOC business hours.
Maintains knowledge KPMAS contractual relationships to coordinate emergent and urgent care in the most appropriate setting.
Maintains and applies knowledge of benefits eligibility and Explanation of Coverage Language (EOC).
Initiates administrative denials as appropriate, including verbal notification to members and/or facilities of denial decisions, grievance/appeals rights and processes.
Follows local, state and federal jurisdictional regulations on applicable activities and projects to ensure regulatory compliance.
Ensures collaborative working relationships with various professional providers and others to determine availability of services to be rendered.
Determines applicability of coordination of benefits for Medicare, Workers' Compensation, and third party liability.
Provides continuous telephone coverage for the Utilization Management Operation Center.
Orients and trains internal and external providers and staff regarding department functions and interdepartmental relationships.
Maintains referral process workflow.
Functions as a member of the Emergency Case Management (ECM) Team to assist in a variety of functions.
Meets or exceeds customer service standards: call handle times/volumes, referral processing accuracy and productivity.
Manages ECM referral work queue and work flows.
Compiles daily and monthly statistical reports.
Performs other related duties as directed.