Care Manager for Geriatric Patient Populations
2 days ago
As a skilled Care Manager, you will play a vital role in coordinating patient care and population-based management for geriatric patients and other specifically defined patient populations. You will work closely with physicians, staff, and non-Kaiser providers/facilities to plan and implement a comprehensive, multi-disciplinary approach to manage health conditions, utilization of resources, and protocols. Your expertise will be essential in developing treatment plans, monitoring care, and making recommendations for alternative levels of care. You will also identify cost-effective protocols and care paths and develop guidelines for care that may require coordination across systems of multiple providers/services.
Key Responsibilities:
- Develop and implement care plans that address the unique needs of geriatric patients and other defined patient populations.
- 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.
- Assess physiological and functional status utilizing established protocols.
- Initiate diagnostic testing/screening and interventions as needed.
- Develop individualized patient/family education plans focused on self-management and deliver patient/family education specific to disease states.
- Implement strategies to target/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 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.
- 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 all 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.
- 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.
- 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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