Department: Patient Care Services Coordination of CareSchedule: On-call, Regular, 00 hours per week, 07:30 - 16:00 (May include weekends, evenings and after hours. Based On Departmental Needs.)Position Summary: Please be aware that this position is currently under review as part of the jurisdictional process with the California Nurses Association to determine whether such position should be assigned to the CNA bargaining unit. This review is on a position-by-position basis and includes an analysis of the actual duties performed in each position under review. This determination will be made within the next several months. Should the determination be made that the position does belong to the CNA bargaining unit, you will be offered the opportunity to (a) follow the work into the CNA bargaining unit and become a member of the union, or (b) seek other employment within the organization. Should you have any questions regarding this notice, please contact your recruiter for further information. 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. 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.Education/License/Certification: Bachelors degree, or equivalent experience, in nursing or health related field. Masters degree preferred. Graduate of an accredited school of nursing. Current California RN license required.PREFERRED Education/License/Certification: BSN or BA in health care related field or Diploma/Associate Degree Nursing (ADN) with comparable years of experience required. Masters Degree preferred. Graduate of accredited school of nursing. Current California RN licensure required, BLS Certification Qualifications: Previous case management experience preferred. Demonstrated experience in utilization management, discharge planning, or transfer coordination. Knowledge of Nurse Practice Act, The Joint Commission and other federal/state/local regulations.PREFERRED Qualifications: Experience (usually 2+ years) in direct patient care delivery or 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.).Duties: Plans, develops, assesses, and evaluates care provided to members. In conjunction with physicians, evaluates and develops discharge plans, recommends alternative levels of care, and ensure compliance with federal, state, and local requirements. Develops and maintains case management policies and procedures. Coordinates, directs, and performs concurrent and retrospective reviews,and monitors level and quality of care. Coordinates the interdisciplinary approach to providing continuity of care, including utilization management, transfer coordination, discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Consults with physicians, health care providers, discharge planning and outside agencies regarding continued care/treatment or hospitalization. Encourages members to follow plans of care (e.g., drug therapy, physical therapy). Makes referrals to appropriate community services. Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum. Develops and collects data, and trends utilization of health care resources. Interprets regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff,contract providers, and outside agencies. Coordinates transmission of clinical and benefit treatment to patients, families and outside agencies.OTHER 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-daystays, 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). Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente�s Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanente�s policies and procedures.