Kaiser Permanente Continuum Administrator in Santa Clara, California
Reporting to the Executive Dir for the Continuum, w/secondary accountability to Area Mrgs, this position is responsible for the development, planning, Mgmt, & the integration & delivery of KFH/HP operational system processes & standards of practice, in alignment w/the organization's mission, strategic business plan, & related performance improvement expectations.
In collaboration w/Reg-l Continuum Administrators achieves/exceeds performance expectations for all areas of continuing care operations, including Home Health/Hospice, SNF, DME, Ambulance, Claims&Referrals, & Eldercare, Palliative Care, ESRD, Psych, Social Srvs, Case Mgmt, Continuing Care UM, Revenue outside the hospital, Shared Continuing Care Srvs, H/HP Benefit Application, Contracts.
Has joint responsibility for Home Health & Hospice, DME, Ambulance, Utilization Mgmt, Social Srvs, & Contracts.
In collaboration w/local & Reg-l Leadership defines & communicates strategic objectives & scope. Articulates issues or problems from a broader organizational/mission perspective.
Creates the structure & processes to develop, implement & evaluate programs, policies & standards for continuing care srvs to ensure coordinated plans of treatment, delivery systems that meet member needs, & cost effective utilization of necessary srvs.
Ensures the integration of quality, srv & efficiency improvements into day-to-day operations.
Establishes appropriate methods to define, categorize, & monitor claims & referred srvs. Provides oversight to the data & reporting systems used to track the performance of continuing care operations.
Works collaboratively w/medical group & labor leadership to recommend srv delivery changes or internalization of srvs where appropriate.
Works w/Reg-l continuing care leadership to establish appropriate case Mgmt programs to monitor & manage the care of members in non-KFH facilities.
Ensures the successful operational implementation of HealthConnect continuing care functionality.
Responsible for the efficient delivery of all continuing care srvs for KP members by overseeing the development, negotiation, & utilization of cost-effective, high quality contracts w/outside providers.
Establishes joint contracting relationships across medical centers where appropriate. In collaboration w/HPRS, establishes policies, procedures & protocols for the reimbursement of claims submitted by KP members for outside srvs to maximize reimbursement revenue from other insurers (e.g., Medicare or Medi-Cal) w/consistent & appropriate interpretation & application of the health plan benefit.
Manages the Health Plan function in ensuring implementation of new deductible plan products w/in the local areas.
Monitors & assesses trends, external environment & internal practices; makes recommendations to develop/adjust strategy to meet the changing business & market conditions.
Builds relationships w/local leadership & community partners to develop & meet utilization targets & related quality goals in the continuum.
Works w/KFH/HP, TPMG & labor leaders to target diseases/conditions such as Palliative Care, Behavioral Health, Elder Care that would benefit from a Reg-l multidisciplinary approach.
Sponsors clinical pathway development, implementation & evaluation.
Builds the case for change & articulates costs & risks for not making change. Champions new ways of meeting targets &/or goals. Explores critical issues not explicitly addressed by others. Anticipates & plans for future issues or problems.
Recommends adjustments to operations to improve efficiency & to meet changing business needs.
This job description is not all encompassing.
- Minimum ten (10) years of experience in clinical and managerial roles in a multi-faceted health care system and multi-service provider setting required.
- Bachelor's degree in health services or business administration, public health, nursing or related discipline required.
License, Certification, Registration
Demonstrated success in meeting/exceeding performance expectations.
Demonstrated expertise in project management, problem solving, verbal and written communication and collaborative working skills.
Demonstrated ability to function collaboratively in a multi-entity partnership environment.
Able to lead and manage through influence and change.
Able to manage various stakeholder interests and demonstrated skills in facilitation, problem solving, decision making, persuasion and team-orientation.
Thorough knowledge of quality assurance, resource management, health plan regulatory and licensing processes including federal and state laws and regulations such as: Knox-Keene Act, Federal HMO Act, Public Employees Medical and Hospital Act, The Joint
Commission, and all applicable Medicare and Medi-Cal regulations.
- Must be able to work in a Labor/Management Partnership environment.
Master's degree in one of the aforementioned fields preferred.
Current valid California RN license strongly preferred.
TITLE: Continuum Administrator
LOCATION: Santa Clara, California
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. 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.