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Care Manager RN

2 months ago

Acton, California, United States CMP Full time
Job Summary:
As a skilled RN, you will play a vital role in coordinating patient care and population-based management for patients in defined geriatric or other patient populations. You will work collaboratively with physicians, staff, and non-Kaiser providers 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 require coordination across systems of multiple providers and services.

Key Responsibilities:
  • Develop and implement individualized patient care plans, assessing and evaluating care provided to members.
  • 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 requirements.
  • Develop and deliver patient/family education plans focused on self-management, specific to disease states.
  • 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 authorizations/approvals/transfers as needed for outside services.
  • Make referrals to appropriate community services and outside providers.
  • Coordinate transmission of clinical and benefit treatment to patients, families, and outside agencies.
  • Consult with internal and external physicians, healthcare providers, discharge planning, and outside agencies regarding continued care/treatment, hospitalization, or referral to support services or placement.
  • Arrange and monitor follow-up appointments.
  • Coordinate repatriation of patients and monitor their quality of care.
  • Develop and collect data; trend utilization of healthcare resources.
  • 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.
  • Identify and recommend opportunities for cost savings and improving the quality of care across the continuum.
  • Interpret regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies.
  • Act as liaison for outside agencies, non-plan facilities, and outside providers.
  • Participate in committees, teams, or other work projects/duties as assigned.
Requirements:
  • Minimum one (1) year clinical experience as an RN in an acute care setting, plus two (2) years clinical experience as an RN in a licensed home health or hospice agency required.
  • For positions in Special Needs & Care Programs (Care Plus/Guidance): Two (2) years clinical experience as an RN in an acute care setting required.
Preferred Qualifications:
  • Case Management Certification preferred.
  • Bachelor's degree in nursing or healthcare-related field preferred.