This position supports Kaiser Permanente´s code of conduct and compliance by adhering to all laws and regulations, accreditation and Licensure requirements, and internal policies and procedures.
This position supports Kaiser Permanente´s code of conduct and compliance by adhering to all laws and regulations, accreditation and Licensure requirements, and internal policies and procedures. Kaiser Permanente is proud to be an equal opportunity/affirmative action employer. DEPARTMENT: Continuity of Care/Multi-Site (Modesto/Stockton) SCHEDULE: Full-Time Regular, 36-40hrs/wk, Night shift. Shift and locations may vary depending on need, 7:00pm to 7:00am. This is a multi-site position. Will work in Modesto and the Stockton facility. EDUCATION/ LICENSE/CERTIFICATION: BSN or BA in health care related field or Diploma/Associate Degree Nursing (ADN) or comparable years of experience required. Masters Degree preferred. Graduate of accredited school of nursing, BLS Certification, and current California RN licensure required. SKILLS TESTING: N/A 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 judgement 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.). POSITION 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. 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, carepaths, 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. 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.