DEPARTMENT:  Continuity of Care

SCHEDULE:  Full-time, regular; 40hrs/week; SHIFT: Day; Monday through Friday 7:30am to 4:30pm

EDUCATION: 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,  BLS Certification, and current California RN licensure required.

POSITION SUMMARY: 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.

QUALIFICATIONS:  Experience (usually 2+ years) in direct patient care delivery 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 judgement 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.).

REQUIRED SKILLS TESTING: N/A

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,  carepaths, 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-day stays, 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  (KP’s code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures.