Case Manager Utilization RN, 40/hr Day

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 pace environment.

• 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.
  

Experience

• Two (2) years combined RN experience in an acute care setting or case management required.
  

Education

• Completion of an accredited RN training program that allows graduates to take RN license exam.
  

License, Certification, Registration

• Registered Nurse License (California)
  

• Basic Life Support
  

• Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques and methods of Utilization review/management, discharge planning or case management.
  

• Working knowledge of regulatory requirements and accreditation standards (TJC, Medicare, Medi-Cal, etc.).
  

• Demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking and problem-solving skills.
  

• Demonstrated ability in planning, organizing, conflict resolution and negotiating skills.
  

• Computer literacy skills required.
  

• Bachelor's degree in nursing or healthcare related field.
  

• Required to work every other weekend.
  

PrimaryLocation : California,Anaheim,Orange Co Anaheim Medical Center

HoursPerWeek : 40

Shift : Day

Workdays : Sun, Mon, Tue, Wed, Thu, Fri, Sat

WorkingHoursStart : 08:30 AM

WorkingHoursEnd : 05:00 PM

Job Schedule : Full-time

Job Type : Standard

Employee Status : Regular

Employee Group/Union Affiliation : B21|AFSCME|SCNSC

Job Level : Individual Contributor

Job Category : Nursing Licensed & Nurse Practitioners

Department : OC Anaheim Medical Center - Utilization Management - 0801

Travel : No

Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.

For jobs where work will be performed in unincorporated LA County, the employer provides the following statement in accordance with the Los Angeles County Fair Chance Ordinance. Criminal history may have a direct, adverse, and negative relationship on the following job duties, potentially resulting in the withdrawal of the conditional offer of employment:

• 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 licensure requirements (where applicable), and Kaiser Permanente's policies and procedures.
  

• Models and reinforces ethical behavior in self and others in accordance with the Principles of Responsibility, adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty, shows consistency in words and actions; follows through on commitments.
  

• Job duties with at least occasional or possible access to: (1) patients, the general public, or other employees; (2) confidential protected health information and other confidential KP information (including employee, proprietary, financial or trade secret information); (3) KP property and assets, for example, electronic assets, medical instruments, or devices; (4) controlled substances regulated by federal law or potentially subject to diversion.