Qualifications: Bachelors degree, or equivalent experience, in nursing or health related field. Masters degree preferred. Graduate of an accredited school of nursing. Current California RN license required. PHN preferred. Previous case management experience preferred. Demonstrated experience in utilization management, discharge planning, or transfer coordination. Knowledge of Nurse Practice Act, The Joint Commission and other federal/state/local regulations. Consistently demonstrates the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to customers, contracted providers, and vendors.
Preferred Qualifications: Bilingual (English/Spanish) preferred. Previous case management experience preferred. Demonstrated experience in utilization management, discharge planning, or transfer coordination. Knowledge of Nurse Practice Act, JCAHO and other federal/state/local regulations. Experience working in a Managed Care setting. Experience working with obese populations. Prior experience in a multidisciplinary team approach. Knowledge of Word, Excel and PowerPoint.
Duties: Coordinates with physicians, staff and non-Kaiser providers and facilities regarding patient care. In conjunction with physicians, develops treatment plan, monitors all clinical activities, makes recommendations for alternative levels of care, identifies cost-effective protocols, and develops guidelines for care. Plans, develops, assesses, and evaluates care provided to members. In conjunction with physicians, evaluates and develops treatment plans, recommends alternative levels of care, and ensures compliance with federal, state, and local requirements. Develops and maintains case management policies and procedures. Coordinates, directs, and performs concurrent and retrospective reviews, and monitors level and quality of care. Coordinates the interdisciplinary approach to providing continuity of care, including utilization management, transfer coordination, discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Consults with internal and external physicians, health care providers, discharge planning and outside agencies regarding continued care/treatment or hospitalization. Arranges and monitors follow up appointments. Encourages member to follow prescribed course of care (e.g., drug therapy, physical therapy). Makes referrals to appropriate community services. Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum. Develops and collects data, and trends utilization of health care resources. Interprets regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies. Coordinates transmission of clinical and benefit treatment to patients, families and outside agencies. Acts as liaison for outside agencies, non plan facilities, and outside providers. Coordinates repatriation of patients and monitors their quality of care. Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanente's policies and procedures. EEO:
Notes: Hours and days may vary to meet the needs of the department and may include day, afternoon or evening shifts, weekends and holidays.
This is a repost of FN.1000293.