Extended Care Management Nurse
1 week ago
The Case Manager for Extended Care Coordination is responsible for overseeing and managing patients receiving skilled care in rehabilitation settings within contracted Skilled Nursing facilities. This role involves verifying benefits, managing patient care until discharge, and issuing necessary denial notifications. Collaborating with primary care physicians, specialists, and the healthcare team, the Case Manager coordinates the execution of chronic disease management programs tailored for patients. This position also works closely with assigned physicians to manage skilled nursing patients, guiding families, patients, and healthcare staff to ensure appropriate levels of care while identifying patients who do not qualify for Continued Skilled stay. Additionally, the Case Manager oversees custodial patients requiring long-term care for chronic disease management in Skilled Nursing Facilities (SNFs).
Key Responsibilities:
Collaborate with physicians and the healthcare team to create individualized care plans based on comprehensive patient assessments and diagnostic evaluations.Continuously monitor and assess patient progress, adjusting treatment plans in partnership with the Multidisciplinary team as necessary.Advise on additional care levels and rehabilitation therapies when medically appropriate.Evaluate the effectiveness and appropriateness of therapeutic and rehabilitative care.Implement strategies to ensure patient and caregiver understanding and compliance with the care plan, working alongside the Multidisciplinary team.Provide tailored education to patients and families, emphasizing self-management techniques.Facilitate individual and team discussions to help patients and families recognize risk factors.Assist patients in resuming normal daily activities by providing referrals for external services and ongoing care.In collaboration with physicians and the healthcare team, develop clinical guidelines, treatment protocols, and evaluate program outcomes.Educate inpatient case managers on transfer appropriateness to Skilled Nursing facilities and related protocols.Ensure safe and suitable patient discharges.Order Durable Medical Equipment (DME) as prescribed by physicians.Utilize senior metrics to assess expected Length of Stay for skilled patients.Provide education to inpatient case managers regarding admission appropriateness to Skilled Nursing facilities and related protocols.Address quality concerns related to patient transfers.Inform members about co-payment responsibilities associated with Skilled Nursing transfers.Maintain communication with physicians and care providers regarding patient progress, evaluating clinical, functional, and psychosocial status.Prepare and issue reports as necessary.Engage in interdisciplinary case conferences and consultations.Consult with physicians regarding senior metrics for appropriate lengths of stay for skilled populations.Contribute to the education of medical and nursing staff through periodic in-service presentations.Participate in inpatient Utilization Management staff meetings.Review and evaluate the quality, appropriateness, and outcomes of diagnostic and therapeutic services and treatment programs.Engage in committees, teams, or other assigned projects and duties.
Qualifications:
Experience
Education
N/ALicenses, Certifications, Registrations
Current California RN license is required.BLS certification.Valid California driver's license with a clean driving record for the past two years.Proof of automobile insurance as mandated by law.Additional Requirements:
Proven ability to apply general and specialized principles, practices, techniques, and methods of utilization review/management, discharge planning, or case management.Familiarity with regulatory requirements and accreditation standards (TJC, Medicare, Medi-Cal, etc.).Strong written and verbal communication, interpersonal, critical thinking, and problem-solving skills.Proficiency in computer literacy is essential.Preferred Qualifications:
Bachelor's degree in nursing or a healthcare-related field is preferred, or equivalent relevant work experience.Case Management Certification is preferred.Notes:
This position requires availability seven days a week and may involve floating to various facilities based on operational needs.-
San Diego, California, United States Kaiser Permanente Full timePosition Overview:The Case Manager for Extended Care Coordination is accountable for overseeing and managing skilled patients as well as temporary skilled patients within rehabilitation settings at contracted Skilled Nursing facilities. This role encompasses verifying benefits, managing patient care until discharge, and issuing denial letters when necessary....
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