Works collaboratively with an assigned panel of physicians to
manage the patient's specialized needs. The managing team does
differ according to the chronic disease. Duties include assessment
to identify member needs and development of specific care
management plan to address needs. In conjunction with the
Physician, implements care/treatment plan by coordinating access to
health services across multiple providers/ disciplines, monitors
care, makes determination to arrange transportation and transfer
patient if indicated, identifies cost-effective measures, makes
recommendations for alternative levels of care and utilization of
resources, promotes self-care management and ensures paper work is
completed. Is an indirect caregiver. Complies with other duties as
described. Must be able to work collaboratively with the
Evaluates and identifies members' needs. Interfaces with Primary
Care Physicians, Specialists and various disciplines on the
development of case management plans/programs.
Monitors and evaluates the effectiveness of the case management
plans and modifies as necessary.
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
Acts as a clinical liaison, per their specialty, with outside
agencies such as County CCS, non-plan facilities, outside
providers, employers and/or workers' compensation carriers and
third party administrators.
Prepares reports, communicates program changes to appropriate
staff and develops protocols in accordance with state
Acts as a patient advocate and educator to assure that the
patient has the knowledge to care for his/her condition and patient
is educated and empowered to be responsible for participating in
the plan of care.
Develops individualized patient/family education plan focused on
self-management, delivers patient/family education specific to a
Develops and updates training and educational materials and
presents to appropriate staff, members and families. Facilitates
patients' return to normal daily activities by teaching and making
appropriate referrals for outside services/continued care.
Consults with internal and external physicians, health care
providers, discharge planners, and outside agencies regarding
continued care/treatment or hospitalization or referral to support
services or placement.
May need to facilitate transportation and housing arrangements
for patient. Coordinates transmission of clinical and benefit
treatment to patients, families and outside agencies.
Participates in data collection and analysis of clinical
outcomes of care and customer satisfaction standards. Participates
in the formulation and implementation/monitoring of action
strategies and outcomes of care or customer service. Ensures that
accurate records are maintained of the care associated with each
Interprets regulations, health plan benefits, policies, and
procedures for members, physicians, medical office staff, and
contract providers and outside agencies.
- Minimum two (2) years of clinical experience as an RN in an
acute care or ambulatory care setting required.
- Bachelor's degree or equivalent experience four (4) years
- License, Certification, Registration
- Current California RN license required.
- Demonstrated ability to utilize/apply the general and
specialized principles, practices, techniques and methods of
utilization review/management, care coordination, transfer
coordination, discharge planning or case management.
- Working knowledge of regulatory requirements and accreditation
standards (TJC, Medicare, Medi-Cal, etc.).
- Demonstrated ability to utilize written and verbal
communication, interpersonal, critical thinking and problem-solving
- Computer literacy skills required.
- Bilingual (English/Spanish) QBS Level II required.
- Bachelor's degree in nursing or healthcare related field
- Case Management Certification or certification in the area of
- May support KP Membership fairs, must be able to lift up to 35
- May include Saturdays and Sundays.
- May include travel.
- Must successfully have passed the bilingual test (within the
last 12 months), or be active in the QBS program.
Primary Location: California,Fontana,Palm Court II Scheduled
Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri, Sat,
Sun Working Hours Start: 8:30 AM Working Hours End: 5:00 PM Job
Schedule: Full-time Job Type: Standard Employee Status: Regular
Employee Group/Union Affiliation: B21|AFSCME|SCNSC Job Level:
Individual Contributor Department: Complete Care - Pop Care Mgmt
Travel: Yes, 5 % of the Time 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.
External 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 and
state laws, as well as applicable local ordinances, including but
not limited to the San Francisco and Los Angeles Fair Chance
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