Case Manager Utilization RN, 40/hr Day

KAISER; San Diego (CA); On-site; USD 85,000 - 105,000; Full time

Job summary

NALHE is seeking a collaborative healthcare professional to coordinate admissions and post-hospital care planning with physicians, families, and the multidisciplinary team. You will act as an advocate, ensuring safe, cost-effective discharge plans while maintaining high-quality patient care.

You will coordinate transfers, ensure compliance with regulatory standards, and participate in care planning rounds to optimize resource use and patient outcomes in a fast-paced environment.

Responsibilities

• Plans, develops, assesses and evaluates care provided to members.
• Collaborates with physicians, other multidisciplinary health care team members and patient/family to develop, implement and document appropriate, individualized care plans to ensure continuity, quality and resource use.
• Recommends alternative levels of care and ensures compliance with federal, state and local requirements.
• Assesses high risk patients in need of post-hospital care planning.
• Develops and coordinates the implementation of a discharge plan to meet patients identified needs.
• Communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies.
• Reviews, monitors, evaluates and coordinates the patient’s hospital stay to ensure timely and efficient delivery of services.
• Participates in Bed Huddles and implements recommendations aligned with patient needs.
• Coordinates interdisciplinary care, including Utilization management, Transfer coordination, and Discharge planning with authorizations for outside services.
• Conducts daily clinical reviews for utilization/quality management across settings (outpatient, ER, inpatient, and non-KFH facilities).
• Acts as liaison between in-patient facilities and referral facilities/agencies, providing case management to referred patients.
• Refer patients to community resources to meet post-hospital needs.
• Coordinates transfer of patients to appropriate facilities and maintains required documentation.
• Adheres to regulatory/accreditation requirements (TJC, DHS, HCFA, CMS, DMHC, NCQA, DOL) and compliance guidelines.
• Educates healthcare team on discharge planning roles and resource use; provides patient education to aid discharge and coping with illness.
• Reports any incidents related to quality, risk, or patient safety per established protocols; participates in data collection for studies and monitoring.
• Coordinates care planning rounds and family conferences; participates in committees or other projects as assigned.

Job description

Job Summary:

Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast paceenvironment.

Essential Responsibilities:

• Plans, develops, assesses and evaluates care provided to members.
• Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use.
• Recommends alternative levels of care and ensures compliance with federal, state and local requirements.
• Assesses high risk patients in need of post-hospital care planning.
• Develops and coordinates the implementation of a discharge plan to meet patients identified needs.
• Communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies.
• Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently.
• Participates in the Bed Huddles and carries out recommendations congruent with the patients needs.
• 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.
• Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities.
• Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred.
• Refers patients to community resources to meet post hospital needs.
• Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation.
• Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL.
• Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources.
• Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness.
• Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities.
• Reviews, analyses and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities.
• Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed.
• Participates in committees, teams or other work projects/duties as assigned.