at kaiser permanente, our focus on total health allows us to work as one. as one team driven by talented, passionate health care professionals. one community focused on making healthy choices. one organization using the latest innovations and most advanced care to serve 12.5 million people across the country. if you’re looking for an opportunity to make a real difference in each member’s mind, body, and spirit, join us at the heart of health care.
case manager continuing care sw - lcsw
coordinates with physicians, staff, and non-kaiser providers/facilities regarding patient care/population based management for patients in specifically defined geriatric or other specifically defined patient populations (e.g., patients with a specific chronic disease, high risk patients) in order to plan and implement a comprehensive, mutli-disciplinary approach to manage health conditions, utilization of resources and protocols, patient self-care, implementation and evaluation of treatment plan across the care continuum (primary, secondary, tertiary and continued care). in conjunction with physicians, develops treatment plan, monitors care, makes recommendations for alternative levels of care, identifies cost-effective protocols and care paths and develops guidelines for care that may require coordination across systems of multiple providers/services.
· plans, develops, assesses and evaluates care provided to members.
· in conjunction with primary care and specialist physicians, evaluates and develops baseline medical and psychosocial evaluations and individualized patient care/treatment plans.
· recommends alternative levels of care and ensures compliance with federal, state, and local requirements.
· makes assessments of physiological and or functional status utilizing protocols.
· initiates appropriate diagnostic testing/screening and interventions.
· develops individualized patient/family education plan focused on self-management; delivers patient/family education specific to a disease state.
· implements strategies to target/assess risk factors and achieve and ensure patient follow-up according to clinical and strategic measures/outcomes.
· produces population based reports on outcomes specific to defined patient populations.
· participates 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.
· develops and maintains case management policies and procedures.
· coordinates care/services with utilization and/or quality reviewers and monitors level and quality of care.
· 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 for patients/families.
· consults with internal and external physicians, health care providers, discharge planning and outside agencies regarding continued care/treatment or hospitalization or referral to support services or placement.
· arranges and monitors follow-up appointments.
· encourages member to follow prescribed course of care (e.g., drug therapy, physical therapy).
· makes referrals to appropriate community services and outside providers.
· identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.
· develops and collects data; trends utilization of health care resources.
· interprets regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies.
· coordinates transmission of clinical and benefit treatment to patients, families and outside agencies.
· acts as liaison for outside agencies, non-plan facilities, and outside providers.
· coordinates repatriation of patients and monitors their quality of care.
· graduate of an academic institution accredited by the council on social work education and a master's degree in social work.
· demonstrated knowledge of case management, discharge planning, transfer coordination; tjc and other federal/state/local regulations.
· must be able to work in a labor/management partnership environment.
· minimum two (2) years of case management experience with the population to be case managed preferred.
· current and valid lcsw highly preferred.
for immediate consideration, please visit http://kp.org/careers for complete qualifications and job submission details, referencing job number 1036166.
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 ordinances.
this position supports kaiser permanente’s code of conduct and compliance by adhering to all laws and regulations, accreditation and licensure requirements, and internal policies and procedures.
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