The Front Line of Patient Care
Our nurse professionals embody what it means to provide the best patient interactions possible. They also advance the art and science of nursing in a patient-centered, healing environment.
Case Manager Continuing Care Coordinator RNLocation: San Diego, CA Additional Locations:
Job Number: 729024 Date posted: 08/22/2018
Coordinates with physicians, staff, and non-Kaiser providers/facilities regarding patient care/ population based management for patients in specifically defined geriatric or other specifically defined patient populations in order to plan and implement a comprehensive, multi-disciplinary approach to manage health conditions, utilization of resources and protocols, patient self-care, implementation and evaluation of treatment plan across the care continuum (primary, secondary, tertiary and continued care). In conjunction with physicians, develops treatment plan, monitors care, makes recommendations for alternative levels of care, identifies cost-effective protocols and care paths and develops guidelines for care that may require coordination across systems of multiple providers/services. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team.
- Plans, develops, assesses and evaluates care provided to members.
- In conjunction with primary care and specialist physicians, evaluates and develops baseline medical and psychosocial evaluations and individualized patient care/treatment plans.
- Recommends alternative levels of care and ensures compliance with federal, state, and local requirements.
- Develops individualized patient/family education plan focused on self-management.
- Delivers patient/family education specific to a disease state.
- Encourages member to follow prescribed course of care (e.g., drug therapy, physical therapy).
- Coordinates care/services with utilization and/or quality reviewers 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/transfers as needed for outside services for patients/families.
- Makes referrals to appropriate community services and outside providers.
- Coordinates transmission of clinical and benefit treatment to patients, families and outside agencies.
- Consults with internal and external physicians, health care providers, discharge planning and outside agencies regarding continued care/treatment, hospitalization or referral to support services or placement.
- Arranges and monitors follow-up appointments.
- Coordinates repatriation of patients and monitors their quality of care.
- Develops and collects data; trends utilization of health care resources.
- Produces population based reports on outcomes specific to defined patient populations.
- Participates with healthcare team/providers in actualizing outcomes by planning, evaluating and implementing decisions and strategies to achieve predetermined cost, clinical, quality, utilization and service outcomes.
- Develops and maintains case management policies and procedures.
- Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.
- Interprets regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies.
- Acts as liaison for outside agencies, non-plan facilities, and outside providers.
- Participates in committees, teams or other work projects/duties as assigned.
- Minimum one (1) year of clinical experience as an RN in an acute care setting, plus two (2) years of clinical experience as an RN in a licensed home health or hospice agency required.
- For positions in Special Needs & Care Programs (Care Plus/Guidance): Two (2) years of clinical experience as an RN in an acute care setting required.
License, Certification, Registration
- Current California RN license required.
- Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques and methods of utilization review/management, discharge planning orcase 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 required.
- Computer literacy skills required.
- Bachelor's degree in nursing or healthcare related field preferred.
- Case Management Certification preferred.
- Knowledge of Medicare criteria for SNF placement is preferred.
- This position is for the Centralized Skilled Nursing Facility Placement division of Continuing Care Services.
- The start and end time of the shifts may flex based on the needs of the department.
About Nursing & Physician Assistant Careers
Through professional practice and leadership, nurses at Kaiser Permanente continually advance the art and science of nursing. But we recognize that what we do is more than clinical practice. We believe that every interaction — whether it is with a patient, a colleague, a physician, or anyone else — has the potential to be extraordinary. And we find that approaching our daily routine with this in mind gives each and every action new meaning and allows us to focus on the moment, empowering us to deliver expert care.
No matter where you are in your nursing career, the size and scope of our organization means you have the resources, technology, tools, and support you need to make a lasting impact.
Physician Assistant Careers
Physician assistants play a powerful and important role in delivering high-quality, informative care. Working directly with patients, their families, colleagues, and supervising physicians, they are vital in defining the overall care experience.
Being a physician assistant at Kaiser Permanente is centered on promoting a healing environment — one that maintains a caring, comforting practice while honoring the unity of the whole patient: mind, body, and spirit.
See What People are Saying About Working at KP
Feb 2, 2018
- Positive Outlook
- Positive opinion of CEO
I worked at Kaiser Permanente full-time (More than 8 years)
Excellent benefits. Great calibre of employees, respectful workplace. Very forward thinking and fosters innovation.Full Review
Come introduce yourself to a member of the Kaiser Permanente team at an upcoming career or professional event. We look forward to meeting you in person.
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