<p>Job Summary:</p> <p>Coordinates with physicians, staff, vendors and DME staff regarding utilization of DME. Manages the performance of a team DME Clerks insuring quality, timeliness and accuracy of work. Responsible for the utilization review of the NONC letters as per the appropriate regulatory guidelines to include but not limited to DMHC, NCQA, Medicare and MediCal. Some weekend and holiday work required.</p> <p>Essential Responsibilities:</p> <ul> <li>Plans, develops, assesses, and evaluates ongoing DME services provided to members. Accountable for the performance of a team of 6-15 DME Clerks. </li><li>This includes oversight and tracking of utilization of ordered item/equipment to ensure quality, timeliness and accuracy of orders placed. </li><li>Evaluates the individual performance of their team members including written annual performance appraisals. </li><li>In conjunction with manager assists with the adjustment of the workflow for their teams of DME clerks. </li><li>Reviews and authorizes the referrals for DME/P&O from KP Physicians for KP members personal and home usage. </li><li>Accurate interpretation of member specific benefits for each request as it applies to the item(s) requested; able to articulate to member the various nuances of their coverage type to include but not limited to KPSA, member cost share, self-funded programs, managed MediCal, HDHP, Traditional etc. </li><li>Prioritizes workflow in order to insure timely clinical review of requests, and timely completion of NONC letters within regulated time frames. </li><li>Medical record review as necessary to ascertain additional information necessary for completion of referral for ordering or for UM review for denial. </li><li>Confers with Regional Consultants over any clinical issues in which a question or problem arises. </li><li>Maintains working knowledge of all coverage criteria and DME Formulary Guidelines. </li><li>Responsible for the utilization management/reauthorization and tracking of equipment for example: oxygen, wound vacs, wheelchairs, breast pumps, Dyna splints, and/or any other regional review initiative. </li><li>And/or any other regional review initiative. </li><li>Promotes/improves member client services by problem solving of member, clinician and provider complaints and or grievances. </li><li>Must have demonstrated history of excellent service skills exhibited by courtesy, cooperative spirit and tact when interacting with patients, families and staff. </li><li>Consistently supports compliance and the Principles of Responsibility (KPs code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures. </li><li>In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. </li><li>Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors. </li></ul>