Job Description

Job Summary:

Coordinates with physicians, staff and non-Kaiser providers and facilities regarding patients transitions and discharge planning. In conjunction with physicians, develops plans of care and discharge plans, and makes recommendations for alternative levels of care as required.

Essential Responsibilities:

• 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.

• Monitors the progression of the discharge plan and facilitates discussions with the multidisciplinary teams.

• Educates other healthcare team members on utilization and care coordination.

• Collaborates with and provides information to patients, families, physicians, and staff regarding the discharge plans and transitions.

• Understands and consistently applies the interpretation, and utilization of member health care benefits.

• Conducts UM, care coordination and discharge planning activities according to all applicable regulatory requirements.

• 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 health care providers and agencies.

• Regulatory: Conducts UM, care coordination, and discharge planning activities according to all applicable regulatory requirements.

• 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.

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Basic Qualifications:

Experience

• Minimum four (4) years of experience in hospital patient care delivery, OR completion of Masters degree in case management program in lieu of minimum years of experience.

Education

• Graduate of accredited school of nursing.
• Diploma/Associate Degree Nursing.

License, Certification, Registration

• Registered Nurse License (California)

• Basic Life Support

Additional Requirements:

• 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 health care benefits associated with various business line (Medicare/KPSA, Commercial/KFH, Medi-Cal, Federal, etc.).
• Must be able to work in a Labor/Management Partnership environment.

Preferred Qualifications:

• Minimum two (2) years of experience in utilization review, case management, and discharge planning preferred.
• Bachelors degree in nursing or a health care related field preferred.
• Masters degree in case management preferred.

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