Responsible for coordinating care for identified members with complex medical conditions in collaboration with hospital physicians, QRM staff (IPCC, CM, SW, PTSP), practitioners, medical office staff and other providers. The goal is to support and facilitate a smooth transition from the acute care setting or skilled nursing facility to alternative levels of care or home.  Collaborates with physicians, telephonic care coordinators, inpatient case management/ social workers, telephonic to create a safe discharge plan for identified complex patients.  Key job functions include assessment of identified members, development of a safe discharge plan from acute inpatient, skilled nursing, LTAC and Inpatient Rehab facilities.  Coordinates post-acute services and follow- up medical care to ensure continuity of care.  The Acute Transitional Case Manager (TCM) will identify and communicate any barriers to discharge plan. Ensures appoints and coordination of post-acute services with vendors.

• Responsible for all transitional case management activities outlined above.
• Conducts timely reviews and refers Transitional Case Management Program or Complex Case Management within designated timeframe per policy and procedure and evaluates priority for continuity of care case management based on established guidelines.
• Performs a thorough and objective telephonic assessment of the member including physical, psychosocial, environmental, financial, and health status expectation through the use of hospital records, contact with the member/family or significant others.
• Develops an individual, mutually established plan of care based on the assessment and utilizing motivational techniques, in conjunction with the KP Hospitalists and other practitioners that identifies specific interventions, objectives and goals with anticipated targeted dates for accomplishment.
• Attends patient care conferences (rounds) as scheduled with QRM physicians, and Telephonic IPCC work together to discuss clinical course, discharge planning and provide feedback on planned interventions, or barriers to care for member self-management to avoid delays and promote smooth transition.
• Proactively, implements the plan of care and specific interventions that will lead to the accomplishment of goals as defined. This may entail implementation prior to member discharge.
• Coordinates the resources necessary to accomplish the goals,and makes recommendations for modifications to the plan of care as necessary.
• Performs telephonic outreach to identified members within 48 hours post hospital discharge and completes assessment of member status.
• Coordinates and communicates plan of care to the Primary and/or Specialist Care providers, including follow-up appointment.
• Makes referral to other KP programs for continued care support.
• Documents all case management interactions and interventions according to departmental guidelines.
• Coordinates and participates in complex case management conferences on a regular basis for members involved in the care and updates the plan of care as necessary.
• Continuously coordinates, monitors, tracks and evaluates all care and services rendered to ensure that quality care is being delivered and in the most appropriate setting.
• Re-assess and reinforce members self-management skills, including symptom and medication management.
• Acts as a resource to facility Case Managers and discharge planners.
• Provides case management updates to practitioners and health care teams.
• Collaborates with the healthcare team to provide referral information and regarding community resource referrals.
• Arranges, coordinates and facilitates appointments for the member as necessary.
• Builds effective working relationships with practitioners and other departments within the health plan.
• Works in conjunction with disease specific population based care department as appropriate.
• Consults with Chief of QRM for potential non-approvals, benefit exceptions and other issues as appropriate.
• Assists in the development of guidelines and protocols.
• Investigates, identifies and reports problems and inefficiencies in existing systems, and recommends changes when appropriate to the Supervisor.
• Under the guidance of the Supervisor and in consultation with other QRM staff, participates in the coordination, planning, development, implementation, and maintenance of all QRM policies and procedures.
• Monitors utilization trends concerning inpatient and outpatient care in the market area, keeping appropriate management informed.
• Refers cases identified as risk management, peer review or quality issues to Quality and Risk Management.
• Provides documentation regarding any pertinent patient information or arrangements for inclusion in the members medical record.
• Works cross-functionally with other departments in striving to meet organizational goals and objectives.
• Participates in call rotation to support after hours and weekend referrals for quality resource management services.
• Acts as a team coach for respective areas of responsibility regarding enhanced customer service, quality of work performed and productivity of staff.
• Knowledgeable and compliant with regional personnel policies and procedures.
• Knowledgeable and compliant with QRM departmental and unit specific policies and procedures.
• Participates in annual regional and departmental compliance training.
• Knowledgeable and compliant with Principles of Responsibility.
• Develops and maintains an awareness of how to report compliance issues and concerns. Consistently supports compliance and the Principles of Responsibility (Kaiser Permanentes Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanentes policies and procedures.
• Your access to protected health information (PHI) will be limited to the minimum necessary required to effectively perform your job.
• May perform other duties as assigned.
• Other duties as assigned.