Job Summary: Responsible for optimizing quality and efficiency of care for hospitalized members by conducting daily utilization and quality reviews, discharge planning, and care coordination. Collaborates with physicians and multidisciplinary teams, developing safe discharge plans, and ensuring compliance with all relevant regulations. The role promotes high customer satisfaction and achieves desired utilization and quality outcomes for the population served.
Essential Responsibilities: Utilizes established criteria, to perform daily inpatient review activities, including prospective, concurrent, and retrospective utilization review for all members requiring inpatient admission.
Performs an admission utilization review upon admission.
Assesses discharge planning needs and documents assessment using designated tools in EMR for all new inpatient admissions within 24 hours and begins the discharge planning process immediately.
Conducts a concurrent utilization review of all patients daily and as appropriate based on criteria and policy.
Assess daily all patients for post-hospital care planning and coordinate discharge plans, ensuring appropriate level of care in the most suitable setting.
Performs daily bedside rounds on patients and/or significant other to update on discharge planning.
Reviews charts daily to ensure progression of plan of care and to prepare for daily discharge planning needs.
Escalate barriers to discharge in real time after usual processes cannot affect discharge.
Leverages written escalation pathways to ensure timely care and timely discharge for patients.
Establishes and evolves a discharge plan in parallel with the medical plan to ensure patients discharge plan is ready at the same time as medical clearance.
Perform and documents a social screening assessment for all patients admitted to hospital and places referrals to internal programs and social workers as appropriate.
Prepares for and attends all scheduled rounds with physician partners and leaders to discuss clinical courses, discharge planning, barriers to care / discharge and quality concerns.
Communicate regularly with hospitalist partners and other healthcare team members to monitor patient progress and address delays or quality issues.
Establishes and maintains contact with patients and their families as appropriate, including the provision of education when needed and planning for discharge along the hospital stay.
Arranges follow up appointments for medical and surgical patients who are discharged home as needed.
Ensure that the appropriate level of care is being delivered in the most appropriate setting.
Performs quality of care and service reviews using identified quality indicators.
Performs readmission reviews and identifies plan of care for discharge to prevent future readmissions.
Send appropriate referrals for post-acute needs.
Secure post-acute services for discharging patients in advance of medical clearance.
Remains knowledgeable of contract benefits and current, relevant state and Federal regulations, criteria, documentation requirements and laws that affect managed care and case/utilization management.
Maintains effective interaction/communication with members of the medical staff, nursing staff, complex case managers, home care review team, social workers, general reviewers, referral coordinators, and Kaiser Permanente medical offices to facilitate the inpatient utilization management process and to provide continuity of care.
Builds effective working relationships with physicians, department staff, post-acute staff, vendors, and other departments within the health plan.
Assists in the development and revision of guidelines, pathways and protocols.
Coordinate case conferences for complex cases and facilitate transfers to appropriate facilities.
Documents a daily progress note in EMR with evolving discharge plan
Refers cases identified as risk or quality issues to the appropriate department for review using the appropriate reporting tool.
Document Review Activities to include (according to policy): Medical necessity for admission. Medical necessity for