Job Summary:

Responsible for working collaboratively with physician partners to optimize quality and efficiency of care for hospitalized members by carrying out daily utilization and quality review, monitoring for inefficiencies and opportunities to improve care, developing a safe discharge plan to include recommending alternative levels and sites of care when appropriate. The activities will include daily review of hospital care by chart review and discussion with attending physician, admission and concurrent review for inpatient admissions, meetings with patient and families to develop discharge planning, identification of patients for ambulatory case management, communication with case managers, home care reviewers, social workers, members and providers, quality improvement reviews, and education of the member/family, provider and hospital staff. Achieves desired utilization and quality outcomes and promotes high customer satisfaction to the population served.

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. Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently. Communicates via huddles with hospitalist partner multiple times throughout the day.
• Reviews all new inpatient admissions within 24 hours and begins the discharge planning process immediately. Assesses high risk patients in need of post-hospital care planning. Develops and coordinates the implementation of a discharge plan to meet each patients identified needs; communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies to enhance the effect of a seamless transition from one level of care to another across the continuum. Ensures that the appropriate level of care is being delivered in the most appropriate setting. Recommends alternative levels of care and ensures compliance with federal, state and local requirements.
• Performs psychosocial assessments on all patients that meet the high risk indicators for discharge planning. Comprehensively assesses patients goals as well as their biophysical, psychosocial, environmental, economic/financial, and discharge planning needs. Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness. Refers patients to the ambulatory case managers, care managers and/or social workers as appropriate. Documents all admissions and discharges in the patients Kaiser Permanente electronic medical record. Makes post discharge follow-up calls to all patients who are not referred to an ambulatory case/care management program.
• Attends scheduled rounds 2 times/week with the Physician Director of Resource Stewardship to discuss clinical course and discharge planning for assigned patients identifying any real or potential delays in care or quality of care issues.
• Acts as a liaison between inpatient facility and referral facilities/agencies and provides case management to patients referred, serving as an advocate for patients and families. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation. Builds highly effective working relationships with physicians, SNF staff, vendors, and other departments within the health plan.

Basic Qualifications:

Experience

• Minimum two (2) years of experience in patient care delivery or completion of Masters degree in Case Management Program in lieu of minimum years of experience.

Education

• Associates Degree Nursing.

License, Certification, Registration

• Registered Professional Nurse License (Georgia)

• Licensed Registered Nurse (Temporary - Georgia)

Additional Requirements:

• Demonstrated advanced communication and interpersonal skills with all levels of internal & external customers, including but not limited to medical staff, patients and families, clinical personnel, support and technical staff, outside agencies, and members of the community.
• Ability to collaborate effectively with multidisciplinary healthcare team.
• Excellent time management skills with the ability to work successfully in a fast-paced environment. Must be self-directed, and have the ability to tolerate frequent interruptions and a demanding work load.
• Functional knowledge of computers.
• Experience with managed health care delivery including Medicare.
• Experience in a payer environment highly desirable.
• Knowledge of funding, resources, services, clinical standards, and outcomes is preferred.
• Complex Case Management Certification preferred.
• Knowledge of the Nurse Practice Act, TJC, DMHC, CMS, NCQA, HIPPA, ERISA, EMTALA & all other applicable federal/state/local laws & regulations.
• Demonstrated strong communication and customer service skills, problem-solving, critical thinking, & clinical judgment abilities.
• Fundamental word processing & computer navigation skills & the ability to interpret & use analytic data in day to day operations.
• Knowledge of healthcare benefits associated with various business lines.

Preferred Qualifications:

• Minimum five (5) years of clinical nursing experience in a hospital setting.
• Minimum five (5) years of professional practice experience in an acute care setting.
• Minimum two (2) years of experience in utilization review, case management, and discharge planning preferred.
• Bachelors Degree in Nursing, Health Care or Masters degree in Case Management.