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.