Registered Nurse - Case Management- Case Manager

Care CoordinatorPlans, develops, assesses and evaluates care provided to members. Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use. Reviews, monitors, evaluates and coordinates the patient's hospital stay to assure that all appropriate and essential services are delivered timely and efficiently. Communicates via huddles with hospitalist partner multiple times throughout the day.Reviews all new inpatient admissions within 24 hours and begins the discharge planning process immediately. Assesses high risk patients in need of post-hospital care planning. Develops and coordinates the implementation of a discharge plan to meet each patient's identified needs; communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies to enhance the effect of a seamless transition from one level of care to another across the continuum. Ensures that the appropriate level of care is being delivered in the most appropriate setting. Recommends alternative levels of care and ensures compliance with federal, state and local requirements.Performs psychosocial assessments on all patients that meet the high risk indicators for discharge planning. Comprehensively assesses patients' goals as well as their biophysical, psychosocial, environmental, economic/financial, and discharge planning needs. Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness. Refers patients to the ambulatory case managers, care managers and/or social workers as appropriate. Documents all admissions and discharges in the patients Kaiser Permanente electronic medical record. Makes post discharge follow-up calls to all patients who are not referred to an ambulatory case/care management program.Attends scheduled rounds 2 times/week with the Physician Director of Resource Stewardship to discuss clinical course and discharge planning for assigned patients identifying any real or potential delays in care or quality of care issues.Acts as a liaison between inpatient facility and referral facilities/agencies and provides case management to patients referred, serving as an advocate for patients and families. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation. Builds highly effective working relationships with physicians, SNF staff.