Care Manager for Geriatric and Chronic Disease Patients
6 days ago
As a Care Manager for Geriatric and Chronic Disease Patients at Kaiser Permanente, you will play a critical role in coordinating patient care and population-based management for patients with specific chronic diseases or high-risk conditions. You will work closely with physicians, staff, and non-Kaiser providers to develop and implement comprehensive, multi-disciplinary treatment plans that address health conditions, resource utilization, and patient self-care across the care continuum.
Key Responsibilities:
- Develop and implement individualized care plans for patients with complex needs.
- Collaborate with primary care and specialist physicians to evaluate and develop baseline medical and psychosocial evaluations and 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 using established protocols.
- Initiate diagnostic testing and interventions as needed.
- Develop patient and family education plans focused on self-management and deliver education specific to disease states.
- Implement strategies to target and assess risk factors and ensure 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 decision-making to achieve predetermined cost, clinical, quality, utilization, and service outcomes.
- Develop and maintain case management policies and procedures.
- Coordinate care and services with utilization and quality reviewers and monitor level and quality of care.
- Coordinate interdisciplinary care and services, including utilization management, transfer coordination, discharge planning, and obtaining authorizations/approvals/transfers as needed.
- Consult with internal and external physicians, healthcare providers, and outside agencies regarding continued care/treatment or hospitalization or referral to support services or placement.
- Arrange and monitor follow-up appointments and encourage members to follow prescribed courses of care.
- Make referrals to community services and outside providers as needed.
- Identify and recommend opportunities for cost savings and improving the quality of care across the continuum.
- Develop and collect data to trend utilization of healthcare resources.
- Interpret regulations, health plan benefits, policies, and procedures for members, physicians, and outside agencies.
- Coordinate transmission of clinical and benefit information 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.
Requirements:
Master's degree in Social Work from an accredited institution.Demonstrated knowledge of case management, discharge planning, transfer coordination, and TJC and other federal/state/local regulations.Ability to work in a Labor/Management Partnership environment.Preferred qualifications include a minimum of two years of case management experience with the population to be case managed and current and valid LCSW licensure.
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Los Angeles, California, United States Kaiser Permanente Full timeJob Summary:As a Care Manager for Geriatric and Chronic Disease Patients, you will play a critical role in coordinating patient care and population-based management for patients with complex needs. You will work closely with physicians, staff, and non-Kaiser providers to develop and implement comprehensive care plans that address the physical, emotional, and...
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