Conducts utilization review for in-house patients and those members at contracted facilities. Assists in the discharge planning process.
Accountable to the Long Term Care Managers in Marin/Sonoma for the implementation, development, and outcomes of the intitiative targeted at improved utilization of skilled nursing facilities for patients with wound care and related needs. The focus of the position is to improve the ability and willingness of SNFs to accept complex wound care patients for care and to improve the quality, outcomes, and cost of such care through consultation, training, and coaching of nursing facility staff. Ability to manage a case load of special needs patients who are at high risk for skin integrity issues and or have wounds. Specific duties include: assess strengths/weaknesses/interests of SNF staff, develop training curricula and materials, provide on-site training and coaching in prevention and care of skin problems, consult on treatment for individual patients, consult on products, coordinate with hospital nursing and ET/Wound staff on complex patients being transferred to SNF, develop recommendations for patients being discharged from SNF to lower levels of care, provide short-term telephone follow-up as appropriate, collect data and prepare simple reports for presentation to pertinent quality improvement and utilization committees. Requires educational training opportunites for SNF Contracts and Kaiser SNF staff. Develops criteria to measure outcomes of role. May be utilized in a consultative role for other areas of the Continuum, and other duties as assigned.
Essential Functions:
- Conducts utilization review for in-house patients and/or members who have been admitted to contracted facilities.
- Conducts clinical reviews based on established treatment criteria.
- Reviews utilization patterns and identifies trends and problems areas for special studies. - Assists other health care providers in the discharge planning process and triaging on alternative unit of care.
- Assists in collecting and assimilating clinical data to enhance the quality of services.
- Generates quality improvement results.
- Collaborates with physicians on clinical reviews, keeps them appraised of Kaiser clinical criteria.
- Reports and investigates unusual occurrences and questions inappropriate decisions based on their professional expertise.
- Interviews patients/caregivers regarding care after hospitalization.
- Counsels on Medicare and health care plan coverage.
- Coordinates referrals to appropriate agencies/facilities.
Qualifications:
Basic Qualifications:
- Previous experience in an inpatient setting (usually two (2) years).
- Previous experience utilization experience required (usually one (1) year).
- Bachelors degree, or equivalent experience, in nursing or a health related field required.
- Master's degree preferred.
- Graduate of accredited school of nursing.
- Current California RN license.
- Clinical expert in area of review preferred.
- Demonstrated knowledge of diagnostic codes.
Preferred Qualifications:
- Minimum of one year experience in Medical-Surgical area and experience providing speicalized therapy in the last two years for patients with wounds and pressure ulcers in the acute, skilled nursing and/or home health setting.
- Extensive knowledge of integumentary systems including pathophysiology.
- Demonstrated skill and knowledge of adult teaching and professional consultation principles.
- Ability to practice independently but collaboratively.
- Ability to develop positive relationships and work effectively with patients, families, SNF staff and multidisciplinary Kaiser SNF team.
- Effective written and verbal communication skills.
- Ability to think programmatically and organize workload in order to produce results that meet program objectives.
- In addtion to the clinical skills must demonstrate a high degree of flexibility, as well as maturity, openness, self-awareness, sense of humor, energy, self-confidence, warmth and commitment to patients and professional development.
- Reliable means of transportation and valid California Driver's license.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.