Utilization Review Nurse

3 days ago

Ontario, California, United States Kaiser Permanente Full time
Job Summary:

As a Utilization Review Nurse at Kaiser Permanente, you will work collaboratively with physicians to coordinate and screen for the appropriateness of admissions and continued stays. Your expertise will be essential in making recommendations to physicians for alternate levels of care when patients do not meet the medical necessity for inpatient hospitalization. You will interact with patients, families, and other disciplines to coordinate safe and acceptable discharge plans, functioning as an indirect caregiver, patient advocate, and manager of patients in the most cost-effective way without compromising quality. Additionally, you will be responsible for transferring stable non-members to planned healthcare facilities, complying with AB 1203, Post Stabilization notification, and adhering to other duties as described. This role requires the ability to work collaboratively with the multidisciplinary team, multitask, and function in a fast-paced environment.

Essential Responsibilities:
  1. Plans, develops, assesses, and evaluates care provided to members.
  2. Collaborates 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.
  3. Recommends alternative levels of care and ensures compliance with federal, state, and local requirements.
  4. Assesses high-risk patients in need of post-hospital care planning.
  5. Develops and coordinates the implementation of a discharge plan to meet patients' identified needs; communicates the plan to physicians, patient, family/caregivers, staff, and appropriate community agencies.
  6. Reviews, monitors, evaluates, and coordinates patients' hospital stays to assure that all appropriate and essential services are delivered timely and efficiently.
  7. Participates in the Bed Huddles and carries out recommendations congruent with patients' needs.
  8. Coordinates 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.
  9. Conducts 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.
  10. Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred.
  11. Refers patients to community resources to meet post-hospital needs.
  12. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation.
  13. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines, including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA, and DOL.
  14. Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources.
  15. Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness.
  16. Per established protocols, reports any incidence of unusual occurrences related to quality, risk, and/or patient safety which are identified during case review or other activities.
  17. Reviews, analyzes, and identifies utilization patterns and trends, problems, or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities.
  18. Coordinates, participates, and/or facilitates care planning rounds and patient family conferences as needed.

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