Qualifications: Graduate of an accredited school of nursing required. Current and valid California RN License required Bachelors Degree in nursing or health care related field such as health services administration preferred Previous clinical experience (minimum two (2) to three (3) years) in an acute care medical center required. Previous experience in UM, Discharge Planning and or Case Management preferred. Working knowledge of regulatory requirements and accreditation standards (Medicare, Medi Cal, and JCAHO, etc.) regulations preferred. Demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking and problem solving skills required. Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques and methods of utilization review/management, discharge planning and case management. Consistently demonstrates the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to customers, contracted providers, and vendor.
Preferred Qualifications: Two (2) to three (3) years of critical care experience.
Duties: Independently identifies and assesses high risk patients in need of post hospital care and follow up, using UM criteria, guidelines, high risk screens, clinical judgement, etc., as appropriate. Collaborates with and provides direction to the physician, 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. 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. Consults with UM Physician Advisor as appropriate. Adheres to internal and external regulatory and accreditation requirements, including but not limited to, JCAHO, DHS, CMS, DMHC, NCQA & DOL. Uses discretion and independent judgement in applying approved UM criteria and guidelines in recommending appropriate levels of care and arranging post discharge care, including InterQual ISD (Intensity of Service, Severity of Illness and Discharge Screen), Durable Medical Equipment Formulary, Medicare Rules and Regulations and Evidence of Coverage, based on the needs of individual patients and characteristics of the local delivery system. Educates physicians, other members of the health care team, and patient/family, regarding interpretation and application of Medicare, MediCal and Health Plan benefits and coverage issues and its interrelationship with efficient and appropriate utilization of resources. Based on assessment of clinical information, physician concurrence and review of individual coverage: issues appropriate letters to patient/family, including notices of non coverage letters (NONC's), etc. Ensures that patients/families understand their rights to appeal when they disagree with a medical determination. If requested service/equipment is determined to be a non covered benefit, assists patient/family, with alternative resources, as able/available. Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources. 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. Analyzes and identifies utilization patterns and trends and participates in the collection and analysis of data for special studies, projects 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. 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.
Notes: Variable days and hours with rotating weekends, will be cross-trained to provide case management in the inpatient and ED setting at 9961 Sierra Ave, Fontana. Will be trained to assist with Med-Cal TAR's and Utilization quality review, may be required to travel to offsite locations for trainings or meetings.