Coordinator, Skilled Nursing Care - On -Call
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- Enhances the delivery of case/care management on a daily basis. Assists the Kaiser Permanente team to enhance - SNF quality at our contracted facilities. Partners with the facility and third party rehabilitation consultant to analyze quality outcome data using statistically valid methodologies and graphics. Negotiates performance improvement activities with facility management as a result of NaviHealth data as well as when care issues are present. Consults with facility management in setting annual quality improvement goals. Addresses high risk, high volume patient care activities through use of continuous quality improvement tools and techniques. Identifies, tracks, and trends adverse events. Identifies and reports significant events. Facilitates root cause analyses. Partners with facility managers in developing systems to improve clinical quality and patient safety. Identifies significant knowledge deficits within care team and addresses them through management partners (Kaiser Permanente and facility). Monitors, reports and interprets compliance survey results. Facilitates understanding and improvement of Nursing Home Compare related scores related to short term patients. Interprets Nursing Home Compare scores for Continuing Care Services quality board reports. Identifies and evaluates opportunities for improvement in patient hand-offs between settings (hospital, ED, SNF, home care, etc). Identifies opportunities to reduce hospital readmissions both while the patient is in the SNF and immediately post SNF discharge. Works with quality and utilization personnel in these settings and programs to improve performance.
- Facilitates efficient care delivery. Supports Kaiser Permanente clinicians in organizing and efficiently providing patient/family care through a variety of means (e.g. gathering data, soliciting and organizing patient/family concerns and priorities, assuring efficient rounding). Facilitates patient care conferences. Assists interdisciplinary care team with the identification and development of care goals consistent with patient/family wishes, clinical prognosis and rehabilitation potential. Identifies barriers to achieving patient discharge and assists the care team in overcoming them on an individual patient and/or gaps in care population basis. Assists the care team in defining patient care goals that must be in order for the patient to successful transfer to a lower level of care. Identifies and addresses unmet patient resource needs (e.g. supplies, equipment, orthotics, transportation, etc) required to achieve desired clinical outcomes, patient safety and efficient care both in the facility and in post discharge lower level of care. Coordinates activities of Kaiser Permanente clinical resources (e.g. outpatient visits, pharmacy, laboratory, imaging services) to assure timely, efficient and quality care. Provides patient case management related to Kaiser Permanente resources. Facilitates patient/family, facility and clinician care conferences to align goals, explore options and plan effective and efficient care transitions.
- Interprets utilization criteria for patients both prior to and during a SNF admission using accessible clinical information. Provides consultation to clinicians regarding last covered day. Educates patient and family regarding utilization criteria and appeal rights. Facilitates completion of inter-rater reliability exercises. Assures consistent application of utilization criteria in compliance with regulations (NCQA, Medicare, etc). Provides utilization oversight of patients at non-contract and out of area facilities.
- Enhances customer service. Meets with patients and family members at the beginning of and throughout the SNF stay. Serves as a liaison between the patient/family and care team (facility staff, Kaiser clinicians and home caregivers). Researches patient/family care and service questions and concerns. Addresses patient/family complaints through timely, effective and culturally competent communication. Serves as a resource for complaint research and resolution and documents in complaint tracking system. Assesses patient and family care wishes related to end of life care. Assures patients at end of life have access to hospice, palliative care and POLSTs. Assures patients/families are aware of out of pocket costs associated with services such as transportation.
- Manages knowledge. Maintains up-to-date clinical knowledge of geriatric and rehabilitation best practices. Maintains up-to-date knowledge of hospital, LTACH, SNF, home health, hospice and palliative care utilization criteria. Maintains up-to-date nursing knowledge of clinical pharmacology. Assesses knowledge deficits of customers (patient/family, clinical staff, management, clinicians). Provides both individual and group education in understanding and applying this knowledge in day to day practice in partnership with management and the clinical care team.
- Minimum two (2) years as a case manager.
- Minimum two (2) years of geriatric clinical practice in home health, hospice, hospital or long-term care setting.
- Bachelors degree in nursing OR four (4) years of experience in a directly related field.
- High School Diploma or General Education Development (GED) required.
- Registered Nurse License (Washington) within 2 months of hire
- Registered Nurse License (Oregon) within 2 months of hire
- This job requires credentials from multiple states. Credentials from the primary work state are required before hire. Additional Credentials from the secondary work state(s) are required post hire.
- Drivers License (in location where applicable)
- Basic Life Support
- Ability to use Microsoft Office software.
- Ability to efficiently utilize computerized medical record.
- Ability to take initiative in addressing quality and utilization issues without prompting.
- Ability to work with angry or hostile individuals in high pressure situations.
- Excellent verbal and written communication and customer service skills.
- Ability to effectively work with a diverse population of patients, families, staff and providers.
- Ability to collect, analyze and report statistically meaningful quality and utilization data.
- Working knowledge of admission criteria for SNF, Home Health, Hospice and Hospital.
- Minimum two (2) years of previous utilization and quality management experience.
- Previous experience working in the long-term care setting.
- Bachelors degree in nursing.
- CPHQ certification in Health Care Quality Improvement or CCM or Certification in geriatric nursing.
- Knowledge of Medicare SNF criteria.
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.