The incumbent will be responsible for the day-to-day management and supervision of the Regional Care Coordination and Case Management department, including program development, implementation, monitoring, performance improvement, and management of the Care Coordination and Case Management Team which may consist of clinical e.g. RN, LVN, LCSW, MSW, and allied health and non-clinical staff. In addition, the incumbent will be working in collaboration with regional and medical center leaders and physicians to provide integrated, seamless, and patient centric care and services, monitoring and evaluation of program outcomes achieved. Essential Responsibilities:
Manages the day-to-day operations of the Regional Care Coordination / Case Management department and team members. Partners with team leads to drive day to day operations.
Provides operations oversight of care coordination, case management, and care transition functions.
Collaborates with internal and external physicians, health care providers, discharge planners, other care managers and outside agencies to ensure that continued care/treatment or hospitalization or referral to support services or placement is available to program members.
Ensures that all operational program activities follow the KP benefits, policy, and with the various regulatory agencies involved with the management and monitoring of medical care and reimbursement and with government legislative directives.
Provides oversight on strategies set by case managers to target/assess risk factors and achieve and ensure patient follow up according to clinical and strategic measures/outcomes.
Ensures adherence to case management policies and procedures.
Ensures appropriate development and implementation of case management plans. Ensures that case managers are developing individualized patient/family education plans focused on self-care management.
Ensures that case managers coordinate care/services with utilization and/or quality reviewers and monitors level and quality of care.
Manages the administrative functions of the Care Coordination and Case Management operations, including space planning/management, identification/proposals for system development/enhancements, recruiting, hiring, training, discipline/reward and termination of Care Coordination/Case Management department staff.
Monitors, reviews, analyzes, and maintains accurate data as it relates to outcomes, effectiveness of case management plans, and trends. Oversees the participation by case managers 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.
Participates and prepares regulatory audits.
Trains case managers on 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.
Works closely with groups across the continuum, including but not limited to Inpatient Case Management, Long Term Care/Skilled Nursing, medical group operations, Quality, Chiefs Groups, to share information and solicit feedback.
Liaisons with other functional groups, including but not limited to, UM Directors, PCM Leaders, Assistant Administrators, Continuing Care, Social Medicine, Long Term Care, Palliative Care, Home Health/ Hospice, to share information and solicit feedback Prepares written and verbal reports on program status, outcome metrics and other deliverables to designated regional and local senior leaders, committees and groups.
Tracks program and case manager productivity and creates performance plan if needed. Serves as clinical resource for escalation questions or concerns by case managers & pharmacists. Creates monthly productivity for each program and develops action plan for areas with low performance.
Performs other duties as assigned.
Minimum three (3) years of supervisory/management experience required.
Bachelors degree in nursing, health administration or public health required.
Graduate of an accredited school of nursing.
License, Certification, Registration
Registered Nurse License (California)
Knowledge and expertise in case management scope of practice, technique and community resources.
Strong conformability with KPHC and the implementation of new modules within KPHC
Demonstrated knowledge of case management, discharge planning, transition of care, transfer coordination; Medicare, Medicaid, Title 22, NCQA, JCAHO, URAC, and other federal/state/local regulations.
Skilled collaborator and team builder.
Ability in planning, organizing, conflict resolution, negotiating and interpersonal skills.
Knowledge regarding compliance requirements by the various regulatory agencies and various legislative directives affecting health care management and reimbursement.
Excellent communication skills, good problem-solving skills, and decision-making skills; PC skills to include Microsoft word, excel, power point, and electronic medical record.
Strong customer service orientation required.
Must be able to work in a Labor/Management Partnership environment.
Minimum five (5) years of case management, or care management experience preferred.
Extensive program development and program management experience in health care provider/payer setting preferred.
Masters degree in nursing or related healthcare field preferred.
Certification as a case manager preferred with experience in home health, discharge planning, utilization management, and/or ambulatory case management desired.
COMPANY: KAISERTITLE: Reg Manager Care Coordinator/Case ManagementLOCATION: Pasadena, CaliforniaREQNUMBER: 1214802External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.