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

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.

• 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.