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Quality Assurance, UR & Case Management

Passion + Vision + Integrity = Excellence

Ensure consistency and the highest ethical standards across our entire organization. Our quality assurance team drives ongoing improvement by fostering an environment of support, providing technical and specialized consultative services, and inspiring ongoing excellence.

Case Manager Utilization RN-PD

Location: Anaheim, CA Job Number: 719970 Date posted: 08/09/2018
Description: 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.

Essential Functions:
  • 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 patient's identified needs; communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies.
  • Reviews, monitors, evaluates and coordinates the patient's 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 patient's 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.

  • Basic Qualifications:
    Experience
  • Two (2) years of clinical experience as an RN in an acute care setting required.
    Education
  • Completion of an accredited RN training program that allows graduates to take RN license exam.
    License, Certification, Registration
  • Current California RN license required.
  • BLS.


    Additional Requirements:
  • 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.

    Preferred Qualifications:
  • Bachelor's degree in nursing or health care related field preferred.
    Primary Location: California,Anaheim,Kraemer II Medical Offices 3430 E. La Palma Scheduled Weekly Hours: 0 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri, Sat, Sun Working Hours Start: 8:30 AM Working Hours End: 5:00 PM Job Schedule: Per Diem Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: SCNSC Job Level: Individual Contributor Job Category: QA / UR / Case Management Department: UR-DISCHARGE PLANNING Travel: No
    Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

    External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.
  • About QA, Ur & Case Management Careers

    Careers In QA, Ur & Case Management

    As an organization, we are committed to delivering the same exemplary care no matter who you are, where you are, or what your needs. But how are those standards defined, measured, and assessed? That's where our quality assurance team comes in. Implementing the action plans and initiatives that will drive successful practices, you'll work across the organization to foster the necessary education, communication, and innovation that will enable us to operate as one KP — with our mission and goals in complete alignment.

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