Case Manager Continuing Care Social Worker-PT/Hrly (Bilingual Spanish) at Kaiser

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.

• N/A.

• Graduate of an academic institution accredited by the Council on Social Work Education and a Masters degree in Social Work.

• N/A

• 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.


• Bilingual (English/Spanish) Level II required.

• Minimum two (2) years of case management experience with the population to be case managed preferred.


• Current and valid LCSW highly preferred.

Notes:

• Dementia clinic completing memory testing, depression screening, and psychosocial assessments for all clinic patients. 


• Case manage patient population. 


• Must successfully pass or have passed the bilingual test (within the last 12 months), or be active in the QBS program.

PrimaryLocation : California,Harbor City,Parkview Medical Offices
HoursPerWeek : 20
Shift : Day
Workdays : Mon, Tue, Wed, Thu, Fri
WorkingHoursStart : 08:00 AM
WorkingHoursEnd : 05:00 PM
Job Schedule : Part-time
Job Type : Standard
Employee Status : Regular
Employee Group/Union Affiliation : NUE-SCAL-01|NUE|Non Union Employee
Job Level : Individual Contributor
Job Category : Behavioral Health, Social Services & Spiritual Care
Department : Parkview MOB - Geriatric Dementia - 0806
Travel : Yes, 10 % of the Time
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.

For jobs where work will be performed in unincorporated LA County, the employer provides the following statement in accordance with the Los Angeles County Fair Chance Ordinance. Criminal history may have a direct, adverse, and negative relationship on the following job duties, potentially resulting in the withdrawal of the conditional offer of employment:

Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's 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 licensure requirements (where applicable), and Kaiser Permanente's policies and procedures.

Models and reinforces ethical behavior in self and others in accordance with the Principles of Responsibility, adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty, shows consistency in words and actions; follows through on commitments.

Job duties with at least occasional or possible access to: (1) patients, the general public, or other employees; (2) confidential protected health information and other confidential KP information (including employee, proprietary, financial or trade secret information); (3) KP property and assets, for example, electronic assets, medical instruments, or devices; (4) controlled substances regulated by federal law or potentially subject to diversion.

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