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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.

Behavioral Health,Transitional Case Manager (RN or LCSW)

Location: Atlanta, GA Job Number: 728683 Date posted: 08/27/2018

Ensures an effective transition of behavioral health patients from the inpatient setting to the next level of care. Provides this via a face to face assessment of identified patients and development of a collaborative care plan for discharge and follow up. Identifies barriers for effective continuity of care while working collaboratively with other BH and medical personnel to resolve those barriers. For At Risk members will monitor discharge plan and follow up care to prevent readmission and ensure ongoing quality of care. Refers patient to internal or external services as indicated by the discharge plan and monitors follow up of referrals. Communicates issues and/or needed improvements on a timely basis to Chief of Behavioral Health to improve quality of care for the patient and/or all members. Overall program goals for this position are: 1) reduce readmissions, 2) improve quality of care metrics for all BH members and 3) enhance member satisfaction.

Essential Responsibilities:

  • Face to face assessments of inpatients including mental and physical health status, psychosocial, financial, activities of daily living, environmental and family support and engagement with the patient.

  • Works with patient's TSPMG clinicians and hospital clinicians to develop a mutually established plan of care to include specific interventions, objectives and goals with anticipated targeted dates for accomplishment. Monitors and tracks quality of patient care and reports any concerns to patient's TSPMG clinicians and/or hospital clinicians. Attends patient care conferences as needed.

  • Utilizes plan of care to establish an agreed upon discharge plan. Implements patient and family teaching as needed to ensure discharge plan occurs on a timely basis. Coordinates necessary resources to ensure timely implementation of the plan. Calls patients within 48 hours of discharge to ensure follow up plan remains intact and determine if patient and/or family has any new questions or concerns. Assess patient's ability to self-manage including symptom and medication management. Reports any concerns to hospital based physicians and/or TSPMG clinician as appropriate and creates resolution plan as needed.

  • Communicates closely with regional Quality Resource Management staff to ensure issues of medical necessity are addressed as needed by the TSM or the QRM staff.

  • Makes referrals to other KP programs or external services as needed and communicates with patient and caregiver to ensure referral takes place. Educates the patient and/or family on all referrals and needed follow up. Ensures that TSPMG physicians are aware of discharge plan and any referral of services.

  • Follows patients for 30 days post discharge to ensure compliance with the plan and/or any new patient concerns.

  • Documents TCM interactions, results of assessment, and proposed discharge plan and potential areas of concerns in Health Connect.

  • Discharges the patient from the TCM program after 30 days with notification and follow up by the appropriate source(s).

  • Builds effective working relationships with hospital and TSPMG personnel.

  • Remains up to date on patient's benefit plan and QRM medical necessity decision for patient's care.

  • Remains knowledgeable of contract benefits, relevant state and federal regulations, criteria documentation requirements, including CMS and laws that affect managed care and utilization management.

  • Adheres to QRM department level policies and procedures.

  • Facilitates medication reconciliation with KP Pharmacist.

  • Basic Qualifications:


  • Minimum two (2) years of Psychiatric inpatient care.

  • Minimum two (2) years of Discharge planning experience and/or Transitional Case Management or Complex Case Management experience working with BH patients.

  • Education

  • Bachelor's degree in nursing or master's degree in social work OR four (4) years of experience in a directly related field.

  • High School Diploma or General Education Development (GED) required.

  • License, Certification, Registration

  • Unrestricted current RN license in the state of Georgia or documentation to show intent to seek license or Unrestricted licensure or credentials for LCSW.

  • Additional Requirements:

  • Working knowledge of principles of utilization management.

  • Georgia driver's license and able to travel within the Atlanta metro area.

  • Functional knowledge of computers and electronic medical records.

  • Working knowledge of DSM IV codes as well as ICD9 and CPT codes.

  • Preferred Qualifications:

  • Prior work experience as BH transitional case manager and/or discharge planner with HMO preferred.
  • Primary Location: Georgia,Atlanta,Regional Office - 9 Piedmont 9 Piedmont Center 34 Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 8:00 AM Working Hours End: 5:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: UFCW - Local 1996 Job Level: Entry Level Job Category: QA / UR / Case Management Department: Utilization Management 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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