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Continuing Care Coordination Specialist

2 months ago

Carlsbad, California, United States Kaiser Full time
Job Summary:

Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce.

This role is responsible for coordinating patient care and population-based management for patients in specifically defined geriatric or other specifically defined patient populations.

Key Responsibilities:
  • Develop and implement comprehensive, multi-disciplinary care plans to manage health conditions, utilization of resources, and patient self-care.
  • Coordinate with physicians, staff, and non-Kaiser providers/facilities to ensure seamless care transitions and optimal patient outcomes.
  • Plan, develop, and evaluate care provided to members, including 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 and disease-specific education.
  • Coordinate care/services with utilization and/or quality reviewers and monitors level and quality of care.
  • Collaborate with interdisciplinary teams to provide continuity of care, including utilization management, transfer coordination, discharge planning, and obtaining authorizations/approvals/transfers as needed.
  • 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, 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.