Registered Nurse Case Manager for Continuing Care

2 weeks ago

San Diego, California, United States Kaiser Permanente Full time

Position Overview:

The role involves collaborating with healthcare professionals, including physicians and support staff, to manage patient care and population health for designated geriatric or specific patient groups. The aim is to establish and execute a thorough, multidisciplinary strategy for addressing health issues, optimizing resource use, and promoting patient self-management throughout the care continuum.

Key Responsibilities:

  • Design, implement, and assess care strategies for members.
  • Work alongside primary care and specialist physicians to create comprehensive medical and psychosocial evaluations and personalized treatment plans.
  • Advise on alternative care levels while ensuring adherence to applicable regulations.
  • Craft tailored educational plans for patients and families, emphasizing self-management and disease-specific information.
  • Motivate members to adhere to prescribed treatment regimens.
  • Facilitate care coordination with quality reviewers, ensuring high standards of care.
  • Oversee the interdisciplinary approach to maintaining care continuity, including management of transfers, discharge planning, and securing necessary authorizations.
  • Refer patients to suitable community resources and external providers.
  • Manage the communication of clinical and benefit information to patients and external entities.
  • Engage with both internal and external healthcare providers regarding ongoing treatment and support services.
  • Schedule and monitor follow-up appointments for patients.
  • Coordinate the safe return of patients and ensure the quality of their care.
  • Collect and analyze data to track healthcare resource utilization.
  • Generate reports focused on outcomes for specific patient demographics.
  • Collaborate with healthcare teams to implement strategies aimed at achieving defined clinical, quality, and service outcomes.
  • Develop and uphold case management policies and procedures.
  • Identify and propose opportunities for cost reduction and quality enhancement across the care spectrum.
  • Interpret regulations and health plan benefits for various stakeholders.
  • Act as a liaison with external agencies and providers.
  • Participate in committees and other projects as required.

Qualifications:

Experience:

Minimum of one (1) year of clinical experience as a Registered Nurse in an acute care environment, along with two (2) years of clinical experience in a licensed home health or hospice setting.

Education:

Refer to the Minimum Work Experience and Qualifications Sections.

Licensure and Certification:

Registered Nurse License (California) and Basic Life Support certification are required.

Additional Skills:

Proven ability to apply principles and practices of utilization review, discharge planning, or case management. Familiarity with regulatory standards and accreditation requirements is essential. Strong communication, critical thinking, and problem-solving skills are necessary, along with proficiency in computer usage.

Preferred Qualifications:

Case Management Certification and a Bachelor's degree in nursing or a related healthcare field are preferred. Experience in Palliative Care and Hospice is also advantageous.

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