Optimizing the quality and efficiency of care for hospitalized members is the core of this role, by conducting daily utilization and quality reviews, discharge planning, and care coordination. The coordinator collaborates with physicians and multidisciplinary teams to develop safe discharge plans and ensure compliance with all relevant regulations, promoting high customer satisfaction and achieving desired utilization and quality outcomes.
Responsibilities
Utilize established criteria to perform daily inpatient review activities, including prospective, concurrent, and retrospective utilization review for all members requiring inpatient admission
Perform an admission utilization review upon admission
Assess discharge planning needs and document assessment using designated tools in EMR for all new inpatient admissions within 24 hours and begin the discharge planning process immediately
Conduct a concurrent utilization review of all patients daily and as appropriate based on criteria and policy
Assess daily all patients for post-hospital care planning and coordinate discharge plans, ensuring appropriate level of care in the most suitable setting
Perform daily bedside rounds on patients and/or significant other to update on discharge planning
Review charts daily to ensure progression of plan of care and to prepare for daily discharge planning needs
Escalate barriers to discharge in real time after usual processes cannot affect discharge
Leverage written escalation pathways to ensure timely care and timely discharge for patients
Establish and evolve a discharge plan in parallel with the medical plan to ensure patients discharge plan is ready at the same time as medical clearance
Perform and document a social screening assessment for all patients admitted to hospital and place referrals to internal programs and social workers as appropriate
Prepare for and attend all scheduled rounds with physician partners and leaders to discuss clinical courses, discharge planning, barriers to care / discharge and quality concerns
Communicate regularly with hospitalist partners and other healthcare team members to monitor patient progress and address delays or quality issues
Establish and maintain contact with patients and their families as appropriate, including the provision of education when needed and planning for discharge along the hospital stay
Arrange follow up appointments for medical and surgical patients who are discharged home as needed
Ensure that the appropriate level of care is being delivered in the most appropriate setting
Perform quality of care and service reviews using identified quality indicators
Perform readmission reviews and identify plan of care for discharge to prevent future readmissions
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Send appropriate referrals for post-acute needs
Secure post-acute services for discharging patients in advance of medical clearance
Remain knowledgeable of contract benefits and current, relevant state and Federal regulations, criteria, documentation requirements and laws that affect managed care and case/utilization management
Maintain effective interaction/communication with members of the medical staff, nursing staff, complex case managers, home care review team, social workers, general reviewers, referral coordinators, and Kaiser Permanente medical offices to facilitate the inpatient utilization management process and to provide continuity of care
Build effective working relationships with physicians, department staff, post-acute staff, vendors, and other departments within the health plan
Assist in the development and revision of guidelines, pathways and protocols
Coordinate case conferences for complex cases and facilitate transfers to appropriate facilities
Document a daily progress note in EMR with evolving discharge plan
Refer cases identified as risk or quality issues to the appropriate department for review using the appropriate reporting tool
Document review activities to include (according to policy): Medical necessity for admission, Medical necessity for continued stay, Estimated length of stay, Diagnoses, Procedures performed, Demographic Data, Discharge Planning, Physicians are involved in care
Issue letters of non-coverage to members not meeting inpatient level of care criteria per established criteria and policy and procedure
Work cross-functionally with other departments in striving to meet organizational goals and objectives
Achieve and maintain an understanding of relevant state and federal regulations, criteria, and documentation requirements and laws that affect managed care, home health and case/utilization management
Be knowledgeable and compliant with regional personnel policies and procedures
Be knowledgeable and compliant with QRM departmental and unit specific policies and procedures
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 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 license requirements (if applicable), and Kaiser Permanente's policies and procedures
Be responsible for assisting the Medical Office Administration, Customer Services and Provider Relations in investigating concerns and issues
Refer to physician advisor when there is disagreement on patient class, level of care, continued stay or discharge
Perform other duties as assigned
Requirements
Minimum two (2) years of RN experience in utilization/case management, discharge planning, quality improvement, or patient care delivery in a healthcare setting
Bachelor's Degree in Nursing or four (4) years of experience in a directly related field
High School Diploma or General Education Development (GED) required
Registered Professional Nurse License (Georgia)
Working knowledge of all relevant federal, state, local and regulatory requirements
Functional knowledge of computers and experience with managed health care delivery, including Medicare
Advanced communication and interpersonal skills with all levels of internal and external customers
Ability to collaborate effectively with multidisciplinary healthcare teams
Excellent time management skills; ability to work in a fast-paced environment
Nice to have:
Experience in a health plan environment is highly desirable
Important Details
Schedule: Monday through Friday with rotating weekends and holidays; 08:30 AM - 05:00 PM
Travel: Yes, 10 % of the time
About the Company
Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces.
As Kaiser Permanente celebrates 80 years of advancing health and care since our founding in 1945, we reflect on the legacy built by the more than 235,000 passionate professionals who have shaped our journey—each one contributing to a stronger, healthier future for our members and communities.
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.
