Description: 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). 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:

• Position for Long term Care at this time. Possible transition to Bridge Clinic


• Must successfully pass or have passed the bilingual test (within the last 12 months), or be active in the QBS program.

Primary Location: California,Bellflower,Bellflower Medical Offices
Scheduled Weekly Hours: 40
Shift: Day
Workdays: Mon, Tue, Wed, Thu, Fri
Working Hours Start: 08:30 AM
Working Hours End: 05:00 PM
Job Schedule: Full-time
Job Type: Standard
Worker Location: Onsite
Employee Status: Regular
Employee Group/Union Affiliation: NUE-SCAL-01|NUE|Non Union Employee
Job Level: Individual Contributor
Department: Bellflower MOB - Internal Medicine-Outpatient - 0806
Pay Range: $101700 - $131560 / year The ranges posted above reflect the location in the job posting. The salary range may vary if you reside in a different location or state than the location posted.
Travel: Yes, 75 % of the Time
On-site: Work location is on-site (KP designated office, medical office building or hospital). Worker location must align with Kaiser Permanente's Authorized States policy. At Kaiser Permanente, equity, inclusion and diversity are inextricably linked to our mission, and we aim to make it a part of everything we do. We know that having a diverse and inclusive workforce makes Kaiser Permanente a better place to receive health care, a more supportive partner in our communities we serve, and a more fulfilling place to work. Working at Kaiser Permanente means that you agree to and abide by our commitment to equity and our expectation that we all work together to create an inclusive work environment focused on a sense of belonging and wellbeing.

Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status. Submit Interest

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