Description: Job Summary:

Conducts utilization review for in-house patients and/or those members at contracted facilities. Assists in the discharge planning process.

Essential Responsibilities:
Conducts utilization review for in-house patients and/or members who have been admitted to contracted facilities. Interviews patients/caregivers regarding care after hospitalization.Conducts clinical reviews based on established treatment criteria.Collaborates with physicians on clinical reviews, keeps them appraised of Kaiser clinical criteria.Reviews utilization patterns, identifies trends and problems areas for special studies.Assists in collecting and assimilating clinical data to enhance the quality of services.Generates quality improvement results.Reports and investigates unusual occurrences and questions inappropriate decisions based on their professional expertise.Assists other health care providers in the discharge planning process and triaging on alternative unit of care.Counsels on Medicare and health care plan coverage.Coordinates referrals to appropriate agencies/facilities.Kaiser Permanente conducts compensation reviews of positions on a routine basis.  At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status.  Such changes are generally implemented only after notice is given to affected employees. Basic Qualifications:
Experience

Minimum two (2) years of experience in an inpatient setting OR if for Skilled Nursing departments, minimum two (2) years of experience in a skilled nursing facility.  
Minimum one (1) year of utilization experience required.

Education

Bachelors degree in nursing or health related field required, OR four (4) years of experience in a directly related field.Graduate of accredited school of nursing.High School Diploma or General Education Development (GED) required.

License, Certification, Registration

Driver's License (California)


Registered Nurse License (California)


Basic Life Support

Additional Requirements:

Demonstrated knowledge of diagnostic codes.
Must be able to work in a Labor/Management Partnership environment.

Preferred Qualifications:

Clinical expert in area of review preferred.
Masters degree preferred.
Utilization Case Management, Home Health and Hospice and Hospital clinical experience and Utilization Review Case manager experience in the SNF