Job Description: Description: Coordinates with physicians, staff, and non-Kaiser providers and facilities regarding patient care. In conjunction with physicians, develops plans of care and discharge plans, monitors all clinical activities, makes recommendations for alternative levels of care, identifies cost-effective protocols, and develops guidelines for care.
Utilization Management: Performs daily pre-admission, admission, and concurrent utilization reviews using guidelines, institutional policies/procedures, and other information to determine appropriate levels of care and readiness for discharge.
Escalates utilization and system problems which have not been resolved at the local level to the next level immediately.
Monitors the progression of the plan of care and facilitates discussions with the multidisciplinary teams.
Educates other healthcare team members on utilization and cost containment initiatives.
Collaborates with and provides information to patients, families, physicians, and staff regarding the provisions of care.
Incorporates and counsels on the correct and consistent application, interpretation, and utilization of member health care benefits (including transition of care).
Discharge Planning: Ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning and obtaining authorizations/approvals as needed for outside services for the patient.
Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social services, and other healthcare providers and agencies.
Performance Improvement: Monitors care processes to provide cost-effective implementation and evaluation of utilization management and patient care activities, initiatives, and protocols.
Participates in the development and implementation of guidelines, pre-printed physician orders, care paths, etc. for patient care.
Identifies and assists in the implementation of opportunities for cost-savings and improvements in the quality of care across the continuum.
Develops, collects, trends, and analyzes data relevant to the utilization of healthcare resources including avoidable/variance days, readmissions, one-day stays, DRGs, LOS, etc.
Participates in the development, implementation, communication, maintenance and monitoring of local UM Workplan initiatives.
Administrative and Regulatory: Shares accountability with the UM Manager for planning, developing, and managing the department budget.
Participates in interviewing, makes hiring recommendations, orients and provides on-going supervision of support staff.
Provides input into the performance evaluations of team members.
May plan and control work assignments and special projects of team members.
Assists in developing, implementing and maintaining utilization management policies and procedures.
Conducts UM, care coordination, and discharge planning activities according to all applicable regulatory requirements (see qualifications).
Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees.
Basic Qualifications: Experience
Minimum two (2) years of experience in patient care delivery or completion of Master's degree in Case Management Program in lieu of minimum years of experience. Education
Graduate of accredited school of nursing.
Diploma/Associate degree in nursing.
High School Diploma or General Education Development (GED) required. License, Certification, Registration
Current California RN licensure required.
Knowledge of the Nurse Practice Act, TJC, DMHC, CMS, NCQA, HIPPA, ERISA, EMTALA & all other applicable federal/state/local laws & regulations.
Demonstrated strong communication and customer service skills, problem-solving, critical thinking, & clinical judgment abilities.
Fundamental word processing & computer navigation skills & the ability to interpret & use analytic data in day to day operations.
Knowledge of healthcare benefits associated with various business lines (Medicare/KPSA, Commercial/KFH, Medi-Cal, Federal, etc.)
Must be able to work in a Labor/Management Partnership environment.
Minimum two (2) years of experience in utilization review, case management, and discharge planning preferred.
Bachelor's degree in nursing or in health care related field preferred.
Master's degree in case management preferred. Primary Location: California,Vacaville,Vacaville Hospital 1 Quality Dr. Scheduled Weekly Hours: 16 Shift: Day Workdays: Week 1: Fri, Sat; Week 2: Sun, Mon Working Hours Start: 8:00 AM Working Hours End: 4:30 PM Job Schedule: Short Hour Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: Non-Union, Non-Exempt Job Level: Individual Contributor Job Category: Nursing Licensed Specialty: Case Management Department: Continuity of Care Travel: No Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.