DEPARTMENT: Continuity of Care
SCHEDULE: Full-Time Regular, 40 hours per week, Day Shifts. Monday through Friday: 8:00am to 5:00pm. Expect schedule to include Weekends and Holidays, work approximately every 3 to 4 weekends and 2 to 3 Holidays a year.
EDUCATION: BSN or BA in health care related field or Diploma/Associate Degree Nursing (ADN) with comparable years of experience required. Masters Degree preferred.
LICENSE/CERTIFICATION: Graduate of accredited school of nursing, BLS Certification, and current California RN licensure required.
JOB SUMMARY: Performs utilization management activities, discharge planning, and care coordination across the continuum of care in collaboration with the physician and other members of the health care team.
QUALIFICATIONS: Experience (usually 2+ years) in direct patient care delivery and management. Demonstrated experience in utilization review, case management, and discharge planning preferred (usually 2+ years). Knowledge of the Nurse Practice Act, The Joint Commission, DMHC, CMS, NCQA, HIPPA, ERISA, EMTALA and all other applicable federal/state/local laws and regulations. Demonstrated strong communication and customer service skills, problem-solving, critical thinking, and clinical judgment abilities. Fundamental word processing and computer navigation skills, and the ability to interpret and 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.).
PREFERRED QUALIFICATIONS: Experience (usually 5+ years) in adult direct patient care delivery with specific experience in cardiovascular, geriatric, Pediatric, NICU, knowledge about Pediatric, NICU, PICU or ICU PICU, & ICU nursing. Working knowledge of Interqual. Management experience is desirable, to enhance ability to interact with and guide interdisciplinary team and treatment planning process. Home Health experience an advantage to enhance knowledge of continuum of care and referrals to various levels of care. Computer/Word Processing/Other: Requires knowledge of mainframe, CIPS, ADT, Lotus Notes, word processing, and elementary spreadsheet construction.
SKILLS TESTING: N/A
DUTIES:
Utilization Management
Performs daily preadmission, 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 (RM/UM Director, CCL, DHO, etc.), immediately. Monitors the progression of the plan of care and facilitates discussions with the multi-disciplinary 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, preprinted 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 Work plan 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).
OTHER DUTIES: This position will support the Utilization Department as an On-Call position. This individual will work closely with the adult and pediatric patient populations, and support associated physicians as the care model is implemented by pairing of MD teams with a PCC.
Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees.
Consistently supports compliance and the Principles of Responsibility (KP's code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures.
In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.
PLEASE NOTE: - Kaiser Permanente is an AA/EEO employer -
