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| Job ID: MD.0901742 |
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Description:
Purpose: (One sentence summary of the job function.)
In general, the Inpatient Case Manager is obligated to maintain and constantly evaluate the appropriateness of a member/patient level of care, to maintain the efficiency and integrity of the referral process, and to monitor the quality of outcomes.
This position consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to the applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanente's policies and procedures. In addition, Regional leaders are accountable for communication, implementation, enforcement, monitoring and oversight of compliance policies and practices in their departments.
Accountabilities: (List of 4-6 primary responsibilities, not activities, in their order of importance)
1. Maintain the data integrity and authorization process of the Referral Management System (RMS).
1.1 Maintain attention to detail and accuracy to optimize the quality of data provided to internal and external customers,
1.2 Schedule and plan work while being sensitive to time constraints and resource
1. Judiciously conserve Health Plan resources.
2.1 Clarify eligibility status in accordance with Health Plan policies and procedures.
2.2 Ensure the appropriate administration of benefits by accurate interpretation and by applying the benefit within limitations, and in a manner that exhibits judgment and a realistic understanding of issues.
2.3 Identify issues, trends, and barriers that delay the patient's timely transition to the next level of care, and accurately communicate this information to others regardless of their status or position.
2.4 Take independent clinical decisions for resource allocation within departmental
2.5 Influence actions and opinions in cases where a physician need assistance to expeditiously transition a patient to the most appropriate level of care.
2.6 Maturely express opinions and use negotiation skills to influence financial outcomes related to hospital days, alternative care and other referred services.
1. Provide case management services.
3.1 Utilize the nursing process approach to prospectively and concurrently formulate and execute plans for health care services in collaboration with MAPMG and community physicians.
3.2 Identify where - support structures exist, identify appropriate referrals and resources and take action and make commitments to solve individual patient care management problems.
3.3 Assess and monitor the plan of care and deal with unresolved situations or unexpected events.
3.4 Develop creative patient care alternatives to ensure the delivery of high quality, cost effective care using analytical problem solving as well as intuition to stimulate new waves of thinking.
3.5 Discuss complex or difficult individual cases with the Manager of Referral Operations, MAPMG physicians and QRM physicians.
3.6 Participate in discharge planning.
1. Provide utilization management services.
4.1 Consistently apply approved utilization review guidelines for services delivered in acute or alternative settings and be able to prioritize objectives.
4.2 Monitor medical necessity for acute care and initiate denial process according to ORM policy where indicated,
4.3 Focus utilization review activities on targeted areas as identified by the QRM department and modify work activities accordingly.
4.4 Provide case finding/screening services and refer patients who need case management services to appropriate staff.
4.5 Exhibit effective, mature problem solving behavior even when dealing with interpersonal conflict, emotional issues or in the face of juggling multiple demands and priorities.
4.6 Demonstrate persistence in problem solving using a reasoned, realistic approach while showing motivation and a sense of urgency.
4.7 Discuss complex or difficult individual cases with Manager of Referral Operations, MAPMG physician managers and QRM physicians.
1. Provide quality screening.
5.1 Demonstrate competency to assess all aspects of care across the continuum for variations from quality and utilization standards.
5.2 Conduct concurrent reviews of specific conditions or procedures as directed and communicate results
5.3 Seek clarification of incomplete or illegible records including inpatient, outpatient and contracting physician office records and report problems for corrective action.
5.4 Identify and report potential risk cases or situations by presenting clear information that builds credibility.
5.5 Exhibit a commitment to the continual improvement in the quality of patient care services.
1. Demonstrate competency to respect patient rights.
6.1 Display an awareness of individual rights of patients and educate the member about those rights.
6.2 Maintain confidentiality of patient records, information, and departmental activities involving patient information.
6.3 Practice within ethical and legal guidelines using established policies and procedures for guidance.
1. Coordinate communication and promote collaboration between the disciplines providing care or case management within and outside the Kaiser Permanente system.
7.1 Optimize productive working relationships by functioning as a liaison, problem solver, and consultant for community social services, health care agencies, providers and various Kaiser Permanente departments.
7.2 Provide case management, utilization and referral management, and benefit interpretation for attending physicians, service chiefs, area physician managers, and medical facility managers.
7.3 Work with Medical Center staff and physicians to develop appropriate plans of care for individual patients or groups of patients in such a way as to build high morale and group commitment to goals and objectives.
1. Demonstrate competency to perform as a team member.
8.1 Collaborate with other QRM staff by assisting with routine department functions in a helpful manner.
8.2 Seek managerial guidance prospectively in cases with high cost potential where benefit management is an alternative, when quality or utilization issues will have a financial impact on Kaiser Permanente or when issues need resolution or clarification.
8.3 Train and orient assigned personnel and alert manager to difficulties or situations that require the manager's personal attention.
8.4 Participate in departmental activities related to education, staff meetings, and guideline and policy development.
8.5 Demonstrate flexibility based on the overall needs of the department.
8.6 Independently schedule and set work priorities while being sensitive to time and resource constraints.
1. Exhibit commitment to act in ways that demonstrate accountability.
9.1 Maintain current knowledge of and seek opportunities for continued learning related to:
9.1.1 Medical diagnosis
9.1.2 Care pathways
9.1.3 Nursing care
9.1.4 Ambulatory care
9.1.5 Utilization management
9.1.6 Member benefits
9.1.7 Medicare benefits
9.2 Complete departmental documentation by writing with clarity and effectiveness.
1. Demonstrate competency to adhere to organizational policies, procedures, and rules.
10.1 Maintain regular attendance and promptness at work in accordance with personnel and/or departmental policy.
10.2 Observe all policies related to time sheets, fire and safety, employee health and dress standards.
10.3 Abide by all policies regarding conduct in the workplace.
10.4 Observe and be a model for regional service standards
1. Performs other related duties as directed.
Minimum Requirement - Relevant Years of Experience:
. One year of experience in acute hospital utilization review or equivalent required,
Minimum Requirement - Education and/or Classes:
. B.S.N. preferred.
Minimum Requirement - License, Certification and/or Designation:
. RN License in jurisdiction where assigned required
. CPR certification required.
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Additional Information:
| Region |
Mid-Atlantic |
| Bargaining Unit |
UFCW - Local 400 |
| Facility |
M WHC |
| Shift |
Day |
| Benefited |
N |
| Employee Referral |
N |
| Area of Interest |
Nursing Lic - Outpt RN Case Management |
| JobType |
Short Hour |
| State/City |
DC, Washington | |
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