Job Summary:Assure timely, appropriate and safe transfer of patients from hospitals, emergency departments, home health/hospice, and outpatient clinics to skilled nursing facilities (SNF) or long term acute care hospitals (LTACH) through a single central placement process. Improve the quality of the hospital to SNF/LTACH transfer process with improved clinical outcomes, patient, clinician and facility satisfaction resulting and efficient use of health care resources. Independently perform ICF utilization reviews and rehabilitation authorizations. Facilitate SNF/LTACH appeal processes. Act as an expert resource consultant to staff and clinicians transitioning patients.Essential Responsibilities:
Facilitate efficient, effective SNF/LTACH placements: Review and evaluate SNF/LTACH referrals using established criteria to assess skilled nursing and rehabilitation needs of referred patients. Verify benefit information and current available SNF days. Match members needs with available SNF/LTACH bed. If needing SNF/LTACH bed out of area, assist with locating appropriate bed. Provide timely and accurate information to KP Provider Relations staff to obtain appropriate spot contracts non-contract facilities. Document in the electronic medical record and/or in the SNF contact record, information necessary to support assessment and authorization for in and out of area placement and referrals. Manage SNF/LTACH utilization: Track bed availability in contract SNF/LTACHs and assign member to first appropriate available bed. Communicate transfers/admissions/placements to GLTC staff, Care Coordinators and others involved in placement process or requiring information for the purpose of tracking utilization, etc.
Resolve barriers to SNF/LTACH placements: Provide member information to SNF/LTACH and problem-solve/facilitate any issues which present a barrier to safe transfers and the provision of quality care, ( e.g. deductible benefit billings, special equipment needs, nursing skills, infusion or parenteral nutrition, incomplete member health information, clinical instability, wound care, respiratory issues, behavioral issues ventilator care, dialysis, interpreter needs or need for additional diagnostic work). Review members pulmonary care needs for SNF/LTACH placement. Assure members meet appropriate regulatory and length of stay guidelines.
Maintain knowledge and serve as a consultant: Develop and maintain expert level of knowledge and skills related to availability of and criteria for regulatory requirements for um and level of care appeals in various health care settings. Act on behalf of member to ensure they are informed and understand their appeal rights and processes if they disagree with a health care determination. Coordinate member request for appeal according to KP policies and procedures with GLTC, facility and KPNW member relations staff.
Develop and maintain expert level of knowledge and skills related to regulatory requirements for ICF/Medicare Part B criteria and utilization management. Review of ICF records for therapists requesting rehabilitation visits for members. Ensure the number of visits requested reflects appropriate utilization of health care resources. Evaluate if the plan is progressing effectively and efficiently toward resolution or transition to an appropriate level of care.
Participate in continuous quality improvement activities. Ensure systematic and ongoing contact with hospital staff/other Kaiser depts. To share information regarding SNF/LTACH placement role and responsibility. Provide leadership in SNF/LTACH transitions with regard to policies and procedures related to patient transition across care settings. Facilitate education of health care staff providing transition assistance for patients with complex needs, ensuring they have sufficient knowledge of AFH, ALF, Home Health, Hospice, Medicare/Medicaid skilled SNF/LTACH UM criteria. Participate in professional committees/task forces as needed/requested. Ensure that UM and regulatory standards are met in collaboration with others in the interdisciplinary health care team. Participate in quality activities. Assist in analyzing SNF/LTACH process data. Identify and implement process improvements which enhance quality and cost in collaboration/partnership with Care Coordinators, Geriatric Long Term Care team, add SNF/LTACH staff and referral sources. Participate in UM activities. Consult with GLTC staff regarding appeals and utilization concerns. Collects quality assurance data and summarizes findings. Triage member inquires. Participate in policy and procedure development and revision. Participate in continuing education to incorporate and maintain up to date knowledge and best practices in leading staff involved with transitional care to SNF/LTACH, performing appeals and ICF utilization reviews, etc.
Perform other duties as requested.
Basic Qualifications:
Experience
Minimum three (3) years of experience as an RN.
Minimum three (3) years of experience in the area of case management, discharge planning or utilization management.
Education
Bachelors degree in nursing from an accredited school OR four (4) years of 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 before 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)
Additional Requirements:
Working knowledge of Medicare and Medicaid regulations for SNF.
Working knowledge of acute, home health/hospice regulations, grievance and case management processes.
Basic word processing knowledge.
Working knowledge of case management techniques and processes.
Working knowledge of the care of chronically ill and frail elderly and needed community resources.
Working knowledge of palliative care of terminally ill patients.
Demonstrate customer-focused service skills.
Demonstrate effective interpersonal communication.
Ability to prioritize patient needs to achieve placement goals.
Excellent time management skills.
Excellent problem-solving skills.
Well developed key-boarding skills.
Preferred Qualifications:
Minimum two (2) years of experience working in a skilled nursing facility.
Minimum five (5) years of acute care hospital experience.
Minimum four (4) years of UM/QA experience or home health/hospice, care coordination, or discharge /transition planning experience.
Case management certification.
Working knowledge of managed care.
Thorough knowledge of Medicare, Medicaid, Nursing facility/LTACH regulations and Health Plan benefits.
Thorough knowledge of member appeal and grievance processes.
Thorough knowledge of quality improvement processes.
Thorough knowledge of appropriate rehabilitation utilization.
Excellent time management, problem-solving and customer service skills.
Ability to connect with members and staff in a caring, respectful manner.
Ability to actively listen to ensure correct message is heard.
Ability to show empathy and sensitivity to members and staffs experiences.
Ability to handle difficult encounters and/or service breakdowns by minimizing emotions and accommodating members/customers.
Ability to use appropriate coping skills in order to maintain positive attitude.
Ability to respond effectively to help or serve others and meet needs.
COMPANY: KAISERTITLE: Placement Coordinator, Skilled Nursing Facilities / Long Term Acute Care (On Call, Days)LOCATION: Portland, OregonREQNUMBER: 1311157External 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, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.