Continuing Care Concurrent Utilization Review Coordinator, RN

This position supports Kaiser Permanente’s code of conduct and compliance by adhering to all laws and regulations, accreditation and Licensure requirements, and internal policies and procedures. Kaiser Permanente is proud to be an equal opportunity/affirmative action employer. DEPARTMENT: Continuing Care SCHEDULE: Full-time, Regular; 40hrs/week; Day Shift: Sunday – Wednesday 7:30AM – 6:00PM. Scheduled days/week are contingent upon departmental needs. Weekend rotation, includes holidays EDUCATION/LICENSE/CERTIFICATION: Bachelors degree, or equivalent experience, in nursing or health related field. Masters degree preferred. Graduate of an accredited school of nursing. Current California RN license required. POSITION SUMMARY: Coordinates with physicians, staff, and non-Kaiser providers and facilities regarding patient care. In conjunction with physicians, develops plans of care and discharge plans, monitors all clinical activities, makes recommendations for alternative levels of care, identifies cost-effective protocols, and develops guidelines for care. QUALIFICATIONS: Previous case management experience preferred. Demonstrated experience in utilization management, discharge planning, or transfer coordination. Knowledge of Nurse Practice Act, The Joint Commission and other federal/state/local regulations. PREFERRED QUALIFICATIONS: Previous experience in an inpatient setting (usually 2 years). Previous utilization experience required (usually 1 year). Clinical expertise in area of review preferred. Demonstrated knowledge of diagnostic codes. DUTIES: Plans, develops, assesses, and evaluates care provided to members. In conjunction with physicians, evaluates and develops discharge plans, recommends alternative levels of care, and ensures compliance with federal, state, and local requirements. Develops and maintains case management policies and procedures. Coordinates, directs, and performs concurrent and retrospective reviews, and monitors level and quality of care. 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. Consults with physicians, health care providers, discharge planning and outside agencies regarding continued care/treatment or hospitalization. Encourages members to follow plans of care (e.g., drug therapy, physical therapy). Makes referrals to appropriate community services. Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum. Develops and collects data, and trends utilization of health care resources. Interprets regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies. Coordinates transmission of clinical and benefit treatment to patients, families and outside agencies. 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.  Kaiser Permanente conducts compensation reviews of positions on a routine basis.  At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status.  Such changes are generally implemented only after notice is given to affected employees. PREFERRED DUTIES: Conducts utilization review for in-house patients as well as those members who have admitted to contracted facilities. Conducts clinical reviews based on established treatment criteria. Reviews utilization patterns, identifies trends and problem areas for special studies. Assists other health care providers in the discharge planning process and triaging on alternative unit of care. Assists in collecting and assimilating clinical data to enhance the quality of services. Generates quality improvement results. Collaborates with physicians on clinical reviews, keeps them appraised of Kaiser clinical criteria.  Reports and investigates unusual occurrences and questions inappropriate decisions based on their professional expertise. Interviews patients/caregivers regarding care after hospitalization. Counsels on Medicare and health care plan coverage. Coordinates referrals to appropriate agencies/facilities.To apply please e-mail resume to Michelle.L.King@kp.org Kaiser Permanente Recruitment ServicesMichelle King, Expert Recruitment ConsultantKaiser Foundation Health Plan, Inc.1761 Broadway, Suite 211Vallejo, CA. 94589Phone: (707) 645-2536 / Tie-Line 8-463-2536Fax: (707) 645-2549 Additional Information Position Type: Full Time, Part Time, Employee