Continuing Care Coordinator RN

1 week ago

Spring Valley, California, United States Kaiser Full time
Job Title:

Geriatric Care Manager - RN

Job Summary:

As a Geriatric Care Manager at Kaiser Permanente, you will play a vital role in coordinating patient care and population-based management for geriatric patients. You will work collaboratively with physicians, staff, and non-Kaiser providers to develop and implement comprehensive care plans that address the unique needs of our patients.

Key Responsibilities:
  • Plan, develop, assess, and evaluate 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 individualized patient/family education plans focused on self-management and deliver patient/family education specific to a disease state
  • Encourage members to follow prescribed courses of care, such as drug therapy and physical therapy
  • Coordinate care/services with utilization and/or quality reviewers and monitor the 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 the 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
  • Registered Nurse License (California)
  • Basic Life Support
Preferred Qualifications:
  • Case Management Certification preferred
  • Bachelor's degree in nursing or healthcare-related field preferred
  • Palliative Care and Hospice experience preferred

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