Geriatric Care Coordinator
1 week ago
As a skilled Case Manager Continuing Care Social Work professional at Kaiser Permanente, you will play a vital role in coordinating patient care and population-based management for geriatric or other specifically defined patient populations. Your comprehensive approach will involve working with physicians, staff, and non-Kaiser providers/facilities to plan and implement a multi-disciplinary treatment plan that addresses health conditions, resource utilization, and patient self-care across the care continuum.
Key Responsibilities:
- Develop and implement individualized care plans that address the unique needs of patients.
- Collaborate with primary care and specialist physicians to evaluate and develop baseline medical and psychosocial evaluations and individualized patient care/treatment plans.
- Recommend alternative levels of care and ensure compliance with federal, state, and local regulations.
- Conduct assessments of physiological and functional status utilizing established protocols.
- Initiate diagnostic testing/screening and interventions as needed.
- Develop and deliver patient/family education plans focused on self-management and disease-specific education.
- Implement strategies to target and assess risk factors and achieve patient follow-up according to clinical and strategic measures/outcomes.
- Produce population-based reports on outcomes specific to defined patient populations.
- Participate in healthcare team/provider decisions to actualize outcomes by planning, evaluating, and implementing decisions and strategies to achieve predetermined cost, clinical, quality, utilization, and service outcomes.
- Develop and maintain case management policies and procedures.
- Coordinate care/services with utilization and/or quality reviewers and monitor level and quality of care.
- Coordinate the interdisciplinary approach to providing continuity of care, including utilization management, transfer coordination, discharge planning, and obtaining authorizations/approvals/transfers as needed for outside services for patients/families.
- Consult with internal and external physicians, healthcare providers, discharge planning, and outside agencies regarding continued care/treatment or hospitalization or referral to support services or placement.
- Arrange and monitor follow-up appointments.
- Encourage members to follow prescribed courses of care (e.g., drug therapy, physical therapy).
- Make referrals to appropriate community services and outside providers.
- Identify and recommend opportunities for cost savings and improving the quality of care across the continuum.
- Develop and collect data; trend utilization of healthcare resources.
- Interpret regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies.
- Coordinate transmission of clinical and benefit treatment to patients, families, and outside agencies.
- Act as liaison for outside agencies, non-plan facilities, and outside providers.
- Coordinate repatriation of patients and monitor their quality of care.
- N/A.
- Graduate of an academic institution accredited by the Council on Social Work Education and a Master's degree in Social Work.
- N/A
Demonstrated knowledge of case management, discharge planning, transfer coordination; TJC and other federal/state/local regulations.Must be able to work in a Labor/Management Partnership environment.Preferred Qualifications:
Minimum two (2) years of case management experience with the population to be case managed preferred.Current and valid LCSW highly preferred.
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