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Case Manager Continuing Care Social Worker
2 months ago
Kaiser Permanente is seeking a skilled Case Manager Continuing Care Social Worker to coordinate patient care and population-based management for patients in geriatric or other specifically defined patient populations. This role involves planning and implementing a comprehensive, multi-disciplinary approach to manage health conditions, utilization of resources and protocols, patient self-care, and implementation and evaluation of treatment plans across the care continuum.
Key Responsibilities:- Case Management: Plans, develops, assesses, and evaluates care provided to members, ensuring compliance with federal, state, and local requirements.
- Care Coordination: In conjunction with primary care and specialist physicians, evaluates and develops baseline medical and psychosocial evaluations and individualized patient care/treatment plans.
- Risk Assessment and Intervention: Makes assessments of physiological and functional status utilizing protocols, initiates appropriate diagnostic testing/screening, and implements strategies to target/assess risk factors and achieve patient follow-up.
- Population-Based Reporting: Produces population-based reports on outcomes specific to defined patient populations.
- Interdisciplinary Collaboration: Participates with healthcare teams/providers in actualizing outcomes by planning, evaluating, and implementing decisions and strategies to achieve predetermined cost, clinical, quality, utilization, and service outcomes.
- Policies and Procedures: Develops and maintains case management policies and procedures.
- Care Coordination and Transfer: Coordinates care/services with utilization and/or quality reviewers and monitors level and quality of care, including utilization management, transfer coordination, discharge planning, and obtaining authorizations/approvals/transfers as needed for outside services.
- Consultation and Referral: Consults 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.
- Follow-up and Education: Arranges and monitors follow-up appointments, encourages members to follow prescribed courses of care, and makes referrals to appropriate community services and outside providers.
- Cost Savings and Quality Improvement: Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.
- Data Collection and Analysis: Develops and collects data, trends utilization of healthcare resources, and interprets regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies.
- Liaison and Coordination: Acts as liaison for outside agencies, non-plan facilities, and outside providers, coordinates repatriation of patients, and monitors their quality of care.
- Education: Graduate of an academic institution accredited by the Council on Social Work Education and a Master's degree in Social Work.
- Experience: Minimum two (2) years of case management experience with the population to be case managed preferred.
- License and Certification: Current and valid LCSW highly preferred.
- Language: Spanish preferred.
