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Job Summary:
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 (e.g., patients with a specific chronic disease, high risk patients) in order to plan and implement a comprehensive, mutli-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). Â 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. Essential Responsibilities:
- 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.
- Makes assessments of physiological and or functional status utilizing protocols.
- Initiates appropriate diagnostic testing/screening and interventions.
- Develops individualized patient/family education plan focused on self-management; delivers patient/family education specific to a disease state.
- Implements strategies to target/assess risk factors and achieve and ensure patient follow-up according to clinical and strategic measures/outcomes.
- 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.
- 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.
- Consults with internal and external physicians, health care providers, discharge planning and outside agencies regarding continued care/treatment or hospitalization or referral to support services or placement.
- Arranges and monitors follow-up appointments.
- Encourages member to follow prescribed course of care (e.g., drug therapy, physical therapy).
- Makes referrals to appropriate community services and outside providers.
- Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.
- Develops and collects data; trends utilization of health care resources.
- Interprets regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies.
- Coordinates transmission of clinical and benefit treatment to patients, families and outside agencies.
- Acts as liaison for outside agencies, non-plan facilities, and outside providers.
- Coordinates repatriation of patients and monitors their quality of care.
Basic Qualifications:
Experience
Basic Quallifications:
- N/A.
Education
- Graduate of an academic institution accredited by the Council on Social Work Education and a Masters degree in Social Work.
License, Certification, Registration
- N/A
Additional Requirements:
- Demonstrated knowledge of case management, discharge planning, transfer coordination; TJC and other federal/state/local regulations.
- Must be able to work in a Labor/Management Partnership environment.
- Bilingual (English/Spanish) Level II required.
Preferred Qualifications:
- Minimum two (2) years of case management experience with the population to be case managed preferred.
- Current and valid LCSW highly preferred.
Notes:
- Must successfully pass or have passed the bilingual test (within the last 12 months), or be active in the QBS program.
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