Skilled Nursing Care Coordinator (36Hrs, Days) - Salem

Job Summary

To optimize the efficiency, effectiveness and quality of clinical care provided by Kaiser Permanente clinicians and facility staff through the use of utilization, case/care management and customer service skills and techniques. To optimize patient/family satisfaction with care received in the SNF setting. To assure efficient and effective transitions of care from to and from the skilled and non-skilled SNF setting.

Essential Responsibilities

• Enhances the delivery of case/care management on a daily basis. Assists the Kaiser Permanente team to enhance -SNF quality at our contracted facilities. Partners with the facility and third party rehabilitation consultant to analyze quality outcome data using statistically valid methodologies and graphics. Negotiates performance improvement activities with facility management as a result of NaviHealth data as well as when care issues are present. Consults with facility management and SNF Operations Manager in setting annual quality improvement goals. Addresses high risk, high volume patient care activities through use of continuous quality improvement tools and techniques. Identifies, tracks, and trends adverse events. Identifies and reports significant events. Facilitates root cause analyses. Partners with facility administration in developing systems to improve clinical quality and patient safety. Assists with identifying significant knowledge deficits within care team and addresses them through partnership (Kaiser Permanente and facility). . Facilitates and interprets understanding and improvement of quarterly quality measures. . s. Identifies and evaluates opportunities for improvement in patient hand-offs between settings (hospital, ED, SNF, home care, etc). Identifies opportunities to reduce hospital readmissions both while the patient is in the SNF and immediately post SNF discharge. Works with quality and utilization personnel in these settings and programs to improve performance.
• Facilitates efficient care delivery. Supports Kaiser Permanente clinicians in organizing and efficiently providing patient/family care through a variety of means (e.g. gathering data, soliciting and organizing patient/family concerns and priorities, assuring efficient rounding). Participates in patient care conferences. . Assists interdisciplinary care team with the identification and development of care goals consistent with patient/family wishes, clinical prognosis and rehabilitation potential. Identifies barriers to achieving patient discharge and assists the care team in overcoming them on an individual patient and/or gaps in care population basis. Assists the care team in defining patient care goals that must be met in order for the patient to successfully transfer to a lower level of care. Collaborates with the facility team to identify and address patient resource needs (e.g. supplies, equipment, orthotics, transportation, etc) required to achieve desired clinical outcomes, patient safety and efficient care, both in the facility and in post discharge care setting. . Assure appropriate utilization of available resources and benefits. Coordinates activities of Kaiser Permanente clinical resources (e.g. outpatient visits, pharmacy, laboratory, imaging services) to assure timely, efficient and quality care. Facilitates interdisciplinary team meetings with facility and clinicians to align goals, explore options and plan effective and efficient care transitions.
• Interprets utilization criteria for patients both prior to and during a SNF admission using accessible clinical information, Medicare criteria and/or Milliman Care Guidelines. Provides consultation to clinicians regarding last covered day. Educates patient and family regarding utilization criteria and appeal rights. Provides notices of non-coverage notices to members that meet benefit and timeliness standards for Medicare and other regulatory compliance requirements. Facilitates completion of inter-rater reliability exercises. Assures consistent application of utilization criteria in compliance with regulations (NCQA, Medicare, etc). Provides utilization oversight of patients at non-contract and out of area facilities. Provide benefit interpretation for copayments and cost sharing.
• Works closely with community physicians and facilities in managing out of area patients to ensure efficient care delivery and appropriate utilization.
• Enhances customer service. Meets with patients and family members at the beginning of and throughout the SNF stay. Serves as a liaison between the patient/family and care team (facility staff, Kaiser clinicians and home caregivers). Researches patient/family care and service questions and concerns. Addresses patient/family complaints through timely, effective and culturally competent communication. Serves as a resource for complaint research and resolution and documents in complaint tracking system. Collaborates with team to assess patient and family care wishes related to end of life care. Collaborates with team to refer patients at end of life to hospice, palliative care and other community programs. Assures patients/families are aware of out of pocket costs associated with services.
• Maintains up-to-date clinical knowledge of geriatric and rehabilitation best practices. Maintains up-to-date knowledge of hospital, LTACH, SNF, home health, hospice and palliative care utilization criteria. Maintains up- to-date nursing knowledge of clinical pharmacology. Assesses knowledge deficits and provides both individual and group education in partnership with management and the clinical care team.

Basic Qualifications

Experience

• Minimum two (2) years as a Case Manager/Care Coordinator.
• Minimum two (2) years of geriatric clinical practice in home health, hospice, hospital or long-term care setting.

Education

• BSN or bachelors degree in a health-care related field or currently enrolled in a BSN program, OR four (4) years of experience of case management or equivalent experience in a directly related field. High School Diploma or General Education Development (GED) required.

License, Certification, Registration

• This job requires credentials from multiple states. Credentials from the primary work state are required at hire. Additional Credentials from the secondary work state(s) are required post hire.
• Registered Nurse License (Washington) within 2 months of hire OR Compact License: Registered Nurse within 2 months of hire
• Registered Nurse License (Oregon) within 2 months of hire
• Drivers License (in location where applicable) required at hire
• Basic Life Support required at hire

Additional Requirements

• Demonstrated ability to interrelate with physicians, nurses, support staff, and patients in interdisciplinary approach.
• Demonstrated ability to work as part of a team and work as a constant patient advocate.
• Basic physical, psychosocial, functional assessment skills.
• Familiar with care processes and systems in settings internal and external to Kaiser Permanente.
• Familiar with and able to collaborate with Kaiser Permanente and community resources.
• Ability to work with angry or hostile individuals in high pressure situations.
• Ability to effectively provide culturally competent care.
• Able to develop concise and thorough documentation of patient clinical assessment and care needs.
• Highly effective problem solving, written and verbal communication, customer service, organizational and time management skills.
• Familiarity with and ability to use computers.
• Ability to collect, analyze and report meaningful quality and utilization data.
• Working knowledge of admission criteria for SNF, Home Health, Hospice, Long Term Acute Care and Inpatient Rehabs.

Preferred Qualifications

• Minimum two (2) years of previous utilization and quality management experience.
• Previous experience working in the long-term care setting.
• CPHQ certification in Health Care Quality Improvement or Certified Case Manager (CCM) or Certification in geriatric nursing.
• Knowledge of Medicare SNF criteria.
• Bachelors degree in nursing.