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RN Utilization Case Manager
1 month ago
Job Summary:
As a Utilization Case Manager RN at Kaiser Permanente, you will work collaboratively with physicians to coordinate and screen for the appropriateness of admissions and continued stays. You will make recommendations to physicians for alternate levels of care when patients do not meet medical necessity for inpatient hospitalization. You will interact with families, patients, and other disciplines to coordinate safe and acceptable discharge plans. You will function as an indirect caregiver, patient advocate, and manage patients in the most cost-effective way without compromising quality. You will transfer stable non-members to planned healthcare facilities and comply with AB 1203, Post Stabilization notification. You will also comply with other duties as described.
Essential Responsibilities:
- Plan, develop, assess, and evaluate care provided to members.
- Collaborate with physicians, other members of the multidisciplinary healthcare team, and patient/family in the development, implementation, and documentation of appropriate, individualized plans of care to ensure continuity, quality, and appropriate resource use.
- Recommend alternative levels of care and ensure compliance with federal, state, and local requirements.
- Assess high-risk patients in need of post-hospital care planning.
- Develop and coordinate the implementation of a discharge plan to meet patients' identified needs.
- Communicate the plan to physicians, patient, family/caregivers, staff, and appropriate community agencies.
- Review, monitor, evaluate, and coordinate patients' hospital stays to assure that all appropriate and essential services are delivered timely and efficiently.
- Participate in Bed Huddles and carry out recommendations congruent with patients' needs.
- Coordinate 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.
- Conduct daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient, and non-KFH facilities.
- Act as a liaison between in-patient facility and referral facilities/agencies and provide case management to patients referred.
- Refer patients to community resources to meet post-hospital needs.
- Coordinate transfer of patients to appropriate facilities; maintain and provide required documentation.
- Adhere to internal and external regulatory and accreditation requirements and compliance guidelines, including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA, and DOL.
- Educate members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources.
- Provide patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness.
- Per established protocols, report any incidence of unusual occurrences related to quality, risk, and/or patient safety which are identified during case review or other activities.
- Review, analyze, and identify utilization patterns and trends, problems, or inappropriate utilization of resources and participate in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities.
- Coordinate, participate, and/or facilitate care planning rounds and patient family conferences as needed.
- Participate in committees, teams, or other work projects/duties as assigned.
Basic Qualifications:
- Experience: Two (2) years combined RN experience in an acute care setting or case management required.
- Education: Completion of an accredited RN training program that allows graduates to take RN license exam.
- License, Certification, Registration: Registered Nurse License (California), Basic Life Support.
Additional Requirements:
- Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques, and methods of utilization review/management, discharge planning, or case management.
- Working knowledge of regulatory requirements and accreditation standards (TJC, Medicare, Medi-Cal, etc.).
- Demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking, and problem-solving skills.
- Demonstrated ability in planning, organizing, conflict resolution, and negotiating skills.
- Computer literacy skills required.
Preferred Qualifications:
- Bachelor's degree in nursing or healthcare-related field.
Notes:
- Every other weekend.
COMPANY:
Kaiser Permanente
TITLE:
Case Manager Utilization RN, 32/hr Days
LOCATION:
Riverside, California
REQNUMBER:
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state, and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.
