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 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 health care 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).
- Experience, usually two (2) + years, in direct patient care delivery and management.
- Demonstrated experience in utilization review, case management, and discharge planning preferred, usually two (2) + years.
- BSN or BA in health care related field OR diploma/associate degree in nursing (ADN) with comparable years of experience required.
- Master's degree preferred.
- Graduate of accredited school of nursing, BLS Certification, and current California RN licensure required.
- Knowledge of the Nurse Practice Act, TJC, 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.)
Schedule: On-Call Regular, 0 hours per week, Day shifts. Position hours are 0800 to 1630 intermittently throughout the week. Working weekends will be required. Hours and days may change based on the needs of department and/or hospital operations
- Basic Life Support/ BLS
- Computer testing may be required
Kaiser Permanente - 12 months ago
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