Case Manager Utilization RN

4 weeks ago

Acton, California, United States Kaiser Permanente Full time
Job Summary

As a Utilization Case Manager RN, you will collaborate with physicians to coordinate and screen admissions and continued stays. You will make recommendations for alternate levels of care when patients do not meet medical necessity for inpatient hospitalization. You will interact with families, patients, and other disciplines to coordinate safe and acceptable discharge plans. You will function as an indirect caregiver, patient advocate, and manage patients in the most cost-effective way without compromising quality. You will transfer stable non-members to planned healthcare facilities. You will be responsible for complying with AB 1203, Post Stabilization notification. You will comply with other duties as described. You must be able to work collaboratively with the multidisciplinary team, multitask, and in a fast-paced environment.

Essential Responsibilities
  • Develop, implement, and evaluate care plans for members.
  • Collaborate with physicians, other healthcare team members, and patients/families to develop, implement, and document individualized plans of care.
  • Recommend alternative levels of care and ensure compliance with federal, state, and local requirements.
  • Assess high-risk patients in need of post-hospital care planning.
  • Develop and coordinate the implementation of discharge plans to meet patients' identified needs.
  • Communicate plans to physicians, patients, families/caregivers, staff, and appropriate community agencies.
  • Review, monitor, evaluate, and coordinate patients' hospital stays to ensure timely and efficient delivery of essential services.
  • Participate in bed huddles and carry out recommendations congruent with patients' needs.
  • Coordinate the interdisciplinary approach to providing continuity of care, including utilization management, transfer coordination, discharge planning, and obtaining authorizations/approvals as needed for outside services for patients/families.
  • Conduct daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in various settings, including outpatient, emergency room, inpatient, and non-Kaiser Permanente facilities.
  • Act as a liaison between in-patient facilities and referral facilities/agencies and provide case management to patients referred.
  • Refer patients to community resources to meet post-hospital needs.
  • Coordinate transfers of patients to appropriate facilities; maintain and provide required documentation.
  • Adhere to internal and external regulatory and accreditation requirements and compliance guidelines, including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA, and DOL.
  • Educate members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources.
  • Provide patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness.
  • Per established protocols, report any incidence of unusual occurrences related to quality, risk, and/or patient safety identified during case review or other activities.
  • Review, analyze, and identify utilization patterns and trends, problems, or inappropriate utilization of resources and participate in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities.
  • Coordinate, participate in, or facilitate care planning rounds and patient family conferences as needed.
  • Participate in committees, teams, or other work projects/duties as assigned.
Basic Qualifications

Experience:

  • Two (2) years combined RN experience in an acute care setting or case management required.

Education:

  • Completion of an accredited RN training program that allows graduates to take RN license exam.

License, Certification, Registration:

  • Registered Nurse License (California)
  • Basic Life Support
Additional Requirements
  • Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques, and methods of utilization review/management, discharge planning, or case management.
  • Working knowledge of regulatory requirements and accreditation standards (TJC, Medicare, Medi-Cal, etc.).
  • Demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking, and problem-solving skills.
  • Demonstrated ability in planning, organizing, conflict resolution, and negotiating skills.
  • Computer literacy skills required.
Preferred Qualifications
  • Bachelor's degree in nursing or healthcare-related field.

Notes:

  • Weekday work schedule with weekend Saturday and Sunday, ED and Inpatient

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