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Senior Utilization Nurse - Hospital Based Medicine - Santa Clara, 40hrs/Days/8's
At Kaiser Permanente our nurses are leaders, clinicians, researchers, innovators, and scientists who are contributing toward being an industry-leading voice for advancing evidence-based care. Whether supporting the patient directly in our hospitals or clinics, providing care at home, serving our patients through innovative virtual technology, or managing care delivery teams, Kaiser Permanente nurses utilize scientific evidence and our integrated care model to optimize the total health of our members and the communities we serve. We invite nurses who are passionate about nursing excellence, high-quality compassionate care delivery, professionalism, integrity, teamwork and patient and family centeredness to join our teams so that we can continue to sustain and build upon our culture of excellence.
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Job Schedule: Full-time
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Scheduled Weekly Hours:
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Shift: Day
Success Profile
We’re looking for Nurse Leaders who possess the following traits.
- Collaborative
- Compassionate
- Flexible
- Leadership
- Socially Conscientious
- Trustworthy
Benefits
We offer several benefits to our nurses.
Our Culture
At Kaiser Permanente, we cultivate an environment of compassion, integrity, trust, and open communication that helps our teams do their best work. We believe that lifelong learning will expand our knowledge so we can better serve our patients. Our practice is rooted in research and evidence-based care. Our nurses reflect the rich diversity of our members and communities and provide culturally responsive and competent care that promotes understanding of our members needs and preferences. At Kaiser Permanente, nurses are highly skilled professionals who exemplify leadership, critical thinking, and collaborative problem solving and deliver the right care, at the right time, in the right setting.
Hear From Our People
Caitlin
Inpatient Lactation Consultant
As an RN/IBCLC in Maternal Child, I’m meeting families at a pivotal time — I’m there to help launch a new family into the world. Everything I do has the potential to impact a family’s health for generations to come.
Kimberly
Quality Coordinator RN
In Hawaii, your community is your family — or ‘ohana.’ I am able to provide extraordinary patient-centered care to my ohana.
David
Appointment and Advice RN
The location is fantastic. Kaiser Permanente is all over the country. You can pick almost any environment you want — from ocean to mountain to city. You’ll still be able to contribute to our mission of providing high quality health care at a local facility.
Shawn
BSN, RN
I chose Kaiser Permanente because their staff and providers really show that they care about you. Also, throughout my 12 years of working here I’m always learning something new, and I’ve had many opportunities for growth and development.
Kristen
Relief Charge Nurse
Working as a nurse at Kaiser Permanente has allowed me the perfect flexible schedule so that I can volunteer as Girl Scout Leader and room parent for both my children. My kids know that I am a hardworking mother who can provide, as well as a mom who can be present and be there for them – and that means everything to me.
Jazmin
RN, Advice Nurse
Working for Kaiser Permanente has allowed me to take control of my future and make my goals a possibility. I feel that Kaiser Permanente allows me to keep climbing and moving. Having that ability truly makes me feel empowered.
Senior Utilization Nurse - Hospital Based Medicine - Santa Clara, 40hrs/Days/8's
In addition to the responsibilities listed below, this position is also responsible for applying advanced clinical and regulatory knowledge of evidence-based guidelines, insurance policies, and clinical criteria to consult on the level of care and duration of treatment required for complex and/or escalated reviews, and providing guidance to team members and collaborating with the health care team, members, and caregivers to assist in discharge planning, cost of care options, and/or coordinating and/or adjudicating referrals to appropriate services based on medical necessity.
- Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional/external stakeholders and customers. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers. Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses; leads by influencing others through technical explanations and examples and provides options and recommendations. Adopts new responsibilities; adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support a business outcome.
- Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions; encourages team members to adapt to and follow all procedures and policies. Collaborates cross-functionally and/or externally to achieve effective business decisions; provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines. Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions.
- Provides high-quality consultation by: leading communication efforts with physicians, managers, staff, members, and/or caregivers regarding requirements related to medical necessity and benefit denials across the continuum of care and resolving communication issues within the work team; and leveraging advanced knowledge to ensure the correct and consistent application, interpretation, and utilization of member health care benefits, cost of care options, and coverage by members and physicians.
- Facilitates education and compliance initiatives by: remaining up-to-date and sharing information with the broader team on the relevant state and federal regulations, guidelines, criteria, and documentation requirements that affect utilization management; and leading the development and delivery of education and training programs for staff and physicians at the local and regional level to promote best practices in utilization management.
- Facilitates quality improvement efforts by: conducting advanced data analyses and developing reports to identify utilization patterns, trends, and opportunities for improvement; providing input and participating in the implementation of corrective action plans to address deficiencies and evaluate effectiveness in utilization review workflows/processes; actively adhering to utilization policies, procedures, and guidelines to ensure compliant and cost-effective care; and developing, refining, and providing oversight for desk-level procedures (e.g., workflows).
- Performs utilization reviews by: following standard policies and procedures when conducting reviews of medical records and treatment plans to evaluate the medical necessity, appropriateness, and efficiency of requested healthcare services, and providing support to team members for reviews; and assessing the ongoing need for services, proactively identifying, anticipating, and escalating potential issues/delays to appropriate stakeholders, and recommending appropriate actions for high-risk member cases.
- Bachelors Degree in Nursing AND minimum five (5) years of experience in direct patient care, utilization review/management or discharge planning in a managed care setting or a directly related field.
- Minimum one (1) year of experience in a leadership role with or without direct reports.
- Registered Nurse License (California) required at hire
- Knowledge, Skills, and Abilities (KSAs): Medical Terminology; Clinical Learning Solutions; Nursing Principles; Information Gathering; Cost Optimization; Written Communication; Confidentiality; Maintain Files and Records; Acts with Compassion; Consulting; Relationship Building; Coordination; Leverages Technology; Member Service; Quality Assurance and Effectiveness; Evidence-Based Medicine Principles
- Three (3) years of experience in utilization review/management.
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Industry Leader
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Ranked among the nation's best
Every hospital that's part of the Kaiser Permanente system earned “high performing” recognition in the latest U.S. News and World Report's annual rankings. That means all 39 of our hospitals are among the top 20% in the nation.
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Awarded for excellence
We're proud that so many of our hospitals have earned Magnet status. It shows our real commitment to outcomes, safety, quality, efficiency, and, most importantly, to our nurses.
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Recognizing nurses during Nurses Month in 2022
We're thanking each one of our 65,000 Kaiser Permanente nurses for everything they've done for us and for the nation. Thank you for choosing to be a nurse and for leading our transformation of care.
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Explore a career in nursing
When you join Kaiser Permanente as a nurse, you'll help us boldly transform care while also building a career that offers more opportunities for you to grow.
Experience nursing excellence
At Kaiser Permanente our nurses are leaders, clinicians, researchers, innovators, scientists, and more. It takes an extraordinary team to offer extraordinary care.
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