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, Review Services Pre-Authorization to join our WPMG HQ team in Renton, Washington.
WPMG is taking on a larger role in ensuring on behalf of KPWA that our members have timely access and authorizations to the clinical services they need. The medical group role will help lead and coordinate the referral and authorization in support of our enterprise strategic initiatives-high quality care and affordable coverage, bringing innovation, value creation, delivering medical excellence, and an unsurpassed patient experience.
Provides operational / strategic direction and support for pre-service across the organization to include pre-authorization, utilization/appeals management, and/or medical review. Directs the implementation of medical policy to ensure correct adjudication of claims in accordance with provider contracts, member contracts, legislative acts, and regulatory mandates. Identifies process and work flow issues as well as recommendations for improvement. Leads company project initiatives. Evaluates and recommends medical policy and provider reimbursement guidelines as they relate to control over medical claims cost. Responsible for contributing to 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.
Ensures departmental compliance with all organization-wide policies and all applicable state and federal regulations. Ensures all appeal/grievance activity is performed within regulatory guidelines (CMS, NCQA, ERISA, Dept. of Insurance Idaho State, Washington State Office of the Insurance Commissioner, etc.) and applicable policies and procedures meet the specified regulatory requirements.
Represents pre-authorization management functions throughout the organization. Provides consultation on complex coverage adjudication. Responds to requests for information from employer groups, external organizations and other internal departments. Ensures facilitation of coverage adjudication.
Values the perspectives of diverse stakeholders including clinical teams, patients and their communities.
Actively builds a culture of equity by understanding health disparities and creating system level interventions to address them.
Encourages front line staff to improve care where they work.
Responsible for management oversight of day-to-day operations functions associated with pre-authorization, denials, inquiries, etc.
Oversees the development, implementation and evaluation of programs as changes are made by various regulatory agencies.
Oversees department operations and mentors' direct reports. Monitors workloads and staff engagement. Maintains department-level budget under the supervision of the Executive Director.
Understands the fundamentals of bias and is able to take this into account as a leader.
Understands the value of diverse teams and demonstrates commitment to diversifying the medical group and leadership
Responsible for contributing to cost savings initiatives which include external delivery system targets and initiatives.
Other duties or projects as assigned.
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
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.
Healthcare related regulatory compliance and coverage adjudication.
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.