This role involves performing all activities for members referred to the complex case management program, including comprehensive clinical evaluation, assessment, and care plan development. The Complex Case Manager coordinates and monitors services with a focus on education and self-management skills, ensuring continuity of care through teamwork with various medical and support staff. The position also educates providers, members, and caregivers to promote quality care and high satisfaction.
Responsibilities
Review all referrals to the Complex Case Management Programs within the designated timeframe per policy and procedure, evaluating for case management based on established guidelines to ensure compliance with NCQA standards
Perform a thorough and objective assessment of the member, including physical, psychosocial, environmental, financial, and health status expectation through the use of EMR and hospital records, contact with the member, significant others, caregivers, and current medical caregivers (if permitted by the member)
Obtain consent from the member/caregiver for participation in Complex Case Management
Develop a comprehensive plan of care based on the assessment and in conjunction with the treating practitioner, identifying specific interventions, objectives, and goals with anticipated targeted dates for member accomplishment and self-management
Communicate the plan of care to the member/caregiver and provide education regarding the member's condition as necessary
Implement the plan of care and specific interventions that will lead to the accomplishment of goals as defined in the plan of care
Establish specific dates for follow-up and assess the member's status and progress toward the established goals, adjusting the plan of care as necessary
Perform referrals to other KPGA programs and coordinate referrals to community resources necessary to accomplish the goals, making recommendations for modifications to the plan of care as necessary
Continuously evaluate and monitor all activities and/or services provided through the case management plan to determine the effectiveness of the plan
Document all case management interactions and interventions according to guidelines, including any pertinent patient information or arrangements in the member's medical record
Identify and evaluate expected outcomes, utilization of services, and associated costs of the plan of care, as well as any proposed alternative plan of care, and make the necessary revisions
Coordinate and participate in case conferences on a regular basis with all providers involved in the care and update the plan of care as necessary
Continuously coordinate, monitor, track, and evaluate all care and services rendered to ensure that quality care is being delivered in the most appropriate setting
Assist in the development and implementation of Continuous Quality Improvement (CQI) projects
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Work closely with the member and practitioner to ensure that the most appropriate and cost-effective services are always provided to the member while maintaining quality outcomes
Perform hospital discharge follow-up on the assigned population, arranging, coordinating, and facilitating appointments for the member as necessary
Maintain effective interaction/communication with members, nursing staff, inpatient care coordinators, the transitional review team, social workers, general reviewers, referral coordinators, and Kaiser Permanente medical offices to facilitate the case management process and to provide continuity of care
Identify the need for discharge from the Case Management Program based on defined goals and criteria, and discharge the member after notifying the member and practitioner, as well as any other resources such as the Social Worker, Transitional Review Team, etc.
Perform as an integrated health care team member, providing continual education to HCT staff as to role and responsibilities in care coordination, remaining accessible to the HCT and attending all HCT meetings as appropriate
Collaborate effectively with providers and other departments within the health plan by acting as a resource to TSPMG providers, contracted consultants, Health Plan administrators, medical office staff, and other departments within the organization
Provide case management updates to providers and health care teams
Perform home visits as appropriate for members in case management
Be knowledgeable and compliant with regional personnel, unit-specific, and departmental policies and procedures, assisting in the development of department protocols as needed
Participate in annual regional and departmental compliance training
Be knowledgeable and compliant with Principles of Responsibility
Consistently support 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 applicable federal, state, and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanente's policies and procedures
Limit access to protected health information (PHI) to the minimum necessary required to effectively perform the job
Demonstrate understanding of HIPAA privacy regulations by maintaining confidentiality of Protected Health Information (PHI)
Demonstrate that doing the right thing and doing things the right way is an underlying premise in all work-related activities and be able to identify the location of a copy of Principles of Responsibility
Develop and maintain an awareness of how to report compliance issues and concerns, identifying issues of wrongdoing and promptly investigating and reporting to the immediate supervisor or Director of Regional Compliance, serving as a primary contact person between the medical offices and community agencies as it relates to coordinating and facilitating the appropriate level of care and provision of services
Collaborate with the social worker to provide information to members and HCTs regarding community resource referrals
Remain knowledgeable of contract benefits and current, industry utilization trends relevant state and federal regulations, criteria, documentation requirements (including Medicare and HCFA), and laws that affect managed care and case/utilization management
Investigate, identify, and report problems and inefficiencies in existing systems, and recommend changes when appropriate to the Team Leader and/or Manager
Under the guidance of the Team Leader and in consultation with other QRM and IQM staff, participate in the coordination, planning, development, implementation, and maintenance of all Complex Case Management Program department policies and procedures
Review the statistics of case management interventions with the Supervisor/Team Leader and adjust based on findings
Perform quality of care and service reviews using identified quality indicators and refer cases identified as risk management, peer review, or quality issues to Quality and Risk Management
Requirements
Minimum five (5) years of RN Clinical Nursing, social work, case management, or utilization management (UM) experience
Equivalent combination of case management/social work/UM training or RN experience may be considered
High School Diploma or General Education Development (GED) required
Licensed Master Social Worker (Georgia) OR Licensed Clinical Social Worker (Georgia) OR Registered Professional Nurse License (Georgia) required at hire
Case Manager Certificate within 12 months of hire from Commission for Case Managers Certification
Complex Case Management experience and/or certification
Excellent/highly skilled in the management of chronic conditions such as diabetes, cardiovascular conditions, behavioral-health, and chronic obstructive lung disease management COPD
Ability to work collaboratively with multiple healthcare professionals
Experience with managed health care delivery, benefits knowledge including Medicare and Medicaid
Functional knowledge of computers
Knowledge of ICD9/ICD10 and/or CPT4 coding beneficial
Working knowledge of all relevant federal, state, local, and regulatory requirements including Medicare/HCFA
Nice to have:
Bachelor's Degree in Nursing strongly preferred or four (4) years of experience in a related field
Kaiser Permanente strives to offer a market competitive total rewards package and is committed to pay equity and transparency. Worker location must align with Kaiser Permanente's Authorized States policy.
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For eight decades, Kaiser Permanente has remained steadfast in its mission to provide high-quality, affordable health care and to improve the health of the communities we serve.
