COORD, QUAL/UM-HOME HEALTH/INF, On Call

Kaiser Permanente; Portland (OR); On-site; USD 95,000 - 120,000; Full time

Job summary

Kaiser Permanente in Portland, OR seeks a Home Health/Infusion Referral Specialist to manage and authorize referred-out services for the Portland metro area and Salem/Longview. Responsibilities include assessing referrals, communicating benefits, and ensuring accurate authorization in Tapestry under supervision.

The role emphasizes quality management, program standardization of benefits, and effective collaboration with vendors and internal teams to optimize patient care across regions.

Qualifications

• Minimum one (1) year of quality management or commensurate knowledge/experience.
• Minimum two (2) years of community health/home health/hospice nursing experience.
• Minimum two (2) years as a registered nurse with experience in the care of the elderly.
• Bachelor's degree or four (4) years of experience in a directly related field.
• High School Diploma or GED required.

Responsibilities

• Analyze referral requests for home health and home infusion to ensure program criteria are met.
• Interpret referral limitations and communicate benefits to members and providers.
• Process referrals for contracted vendors in Portland, Salem and Longview per contracts and service agreements.
• Authorize and amend home health/home infusion services in the system as directed.
• Monitor quality/utilization data and report findings to stakeholders.
• Attend interdisciplinary group meetings and collaborate with outside agencies.

Skills

Communication

Problem solving

Project management

Quantitative skills

Customer service

Analytical thinking

Education

Bachelor's degree or equivalent experience

High School Diploma or GED

Tools

KP Healthconnect

Tapestry

Microsoft Excel

Windows

Database applications

Job description

Job Summary

Under direct and indirect supervision manages, analyzes, processes and authorizes referred out home health and home infusion referrals for Portland metro area and Salem/ Longview.

Essential Responsibilities

• Under direct and indirect supervision, analyzes referral requests for home health and home infusion to assure they meet established program criteria. Interprets referral limitations, Benefits and communicates this information to members, non-plan providers, NWP providers and other internal staff as appropriate. Receives information from contracted and non-contracted vendors related to the admission of KP members. Processes referrals for contracted vendors in Portland, Salem and Longview according to Provider Contracting agreements and Health Plan Service Agreements. Communicates benefit information to home health and home infusion providers. Accurately provides authorization for home health and home infusion in Tapestry as directed by the Home Health Manager or designee. Amends authorizations under the direction of the Home Health manager or designee. Maintains authorization binders and referral logs. Provides additional data as requested by vendor.
• Implement the Quality Management program plan through the strategic collection and analysis of quality and utilization data for outsourced patients.
• Reviews plan of care and visits appropriate to care needs. Ensures standardization of benefits and services across the region.
• Identifies and assists with timely transitions across programs.
• Under direct and indirect supervision, processes referrals for Portland, Salem and Longview Home Health and Home Infusion when programs are at capacity and require referrals to be processed to outside vendors. Assess vendor capacity to accept new referrals. Secures spot contracts as needed. Provide authorization for services. Accurately maintains referred out statistics. Closes authorizations at end of care episode with discharge date and number of visits or days utilized.
• Monitor Home Health Notice of Non-coverage Line: Remove messages. Send notice of non-coverage to patient or Power of Attorney for signature. Maintain notice of non-coverage log.
• Assist in the development and continuous improvement of the Quality Management Program for Continuing Care Services through a variety of planning and evaluation activities. Communicate findings of ongoing quality/utilization monitors to appropriate individuals utilizing written and verbal reports, charts and graphics.
• Attends Interdisciplinary Group meetings for outside agencies per manager request. Develops working relationships with outside agencies that includes site visits on an annual basis.

Basic Qualifications

Experience

• Minimum one (1) year of quality management or commensurate knowledge/experience.
• Minimum two (2) years of community health/home health/hospice nursing experience.
• Minimum two (2) years as a registered nurse with experience in the care of the elderly.

Education

• Bachelors degree OR four (4) years of experience in a directly related field.
• High School Diploma or General Education Development (GED) required.

License, Certification, Registration

• This job requires credentials from multiple states. Credentials from the primary work state are required at hire. Additional Credentials from the secondary work state(s) are required post hire.
• Registered Nurse License (Washington) within 6 months of hire OR Compact License: Registered Nurse within 6 months of hire
• Registered Nurse License (Oregon) within 6 months of hire
• Drivers License (in location where applicable)
• Basic Life Support

Additional Requirements

• Working knowledge of quality/utilization management, risk management and infection control principles.
• Thorough knowledge of Home Health Medicare certification, state licensure.
• Regulations and The Joint Commission accreditation standards.
• Basic knowledge of continuous quality improvement principles.
• Demonstrates customer-focused service skills.
• Computer/word processing skills.
• Excellent written and verbal communication skills; analytical problem-solving skills; well developed project management skills; competent quantitative skills.
• Experience with working in a setting using Medicare Home Health Conditions of Participation.
• Working knowledge of office machines, including PC-based computer systems (Windows), word processing, spreadsheet applications, data base applications.
• Demonstrates customer-focused service skills.
• Good written and verbal skills
• Knowledge of Home Health Conditions of Participation and The Joint Commission standards.

Preferred Qualifications

• Minimum three (3) years of years as a public health nurse in a home health or hospice agency.
• Minimum one (1) year of years supervisory experience.
• Minimum one (1) year of experience in discharge planning/utilization management.
• Thorough knowledge of Kaiser Permanente organization and structure; medical terminology.
• Thorough knowledge of continuous quality improvement principles, tools and practices.
• Effective problem solving, analytical, and organizational skills.
• Working knowledge of KP computer systems including Healthconnect, common membership, and Tapestry.
• Working knowledge of Microsoft Excell.
• Basic knowledge of Provider relations and contractual agreements.
• Ability to work independently with indirect supervision, assimilates technical information, and maintains effectiveness in a busy environment.
• Masters degree in nursing, public health, business or health care administration.

Notes

Shifts/days/working hours may vary.