Patient Care Coordinator / Transplant Coordinator SO.0800526

DEPARTMENT:  Medicine - Nephrology SCHEDULE:  Full-time regular; 40hrs/week; Day Shift; Monday - Friday, Scheduled hours are contingent upon departmental needs. EDUCATION:  Bachelors degree, or equivalent experience, in nursing or health related field. Masters degree preferred. CERTIFICATION/LICENSE:  Graduate of an accredited school of nursing. Current California RN license required. JOB SUMMARY:  Coordinates with physicians, staff, and non-Kaiser providers and facilities regarding patient care. In conjunction with physicians, develops plans of care and discharge plans, monitors all clinical activities, makes recommendations for alternative levels of care, identifies cost-effective protocols, and develops guidelines for care. QUALIFICATIONS:  Previous case management experience preferred. Demonstrated experience in utilization management, discharge planning, or transfer coordination. Knowledge of Nurse Practice Act, The Joint Commission and other federal/state/local regulations. PREFERRED QUALIFICATIONS: Coordinates with physicians, staff and non-Kaiser providers and facilities regarding patient care. In conjunction with physicians, develops plans of care and discharge plans, monitors all clinical activities, makes recommendations for alternative levels of care, identifies cost-effective protocols, and develops guidelines for care.  Previous case management experience preferred. Demonstrated experience in utilization management, discharge planning, or transfer coordination. Knowledge of Nurse Practice Act, The Joint Commission and other federal/state/local regulations. Coordinates with physicians, staff and non-Kaiser providers and facilities regarding patient care. In conjunction with physicians, develops plans of care and discharge plans, monitors all clinical activities, makes recommendations for alternative levels of care, identifies cost-effective protocols, and develops guidelines for care.DUTIES:  Plans, develops, assesses, and evaluates care provided to members. In conjunction with physicians, evaluates and develops discharge plans, recommends alternative levels of care, and ensures compliance with federal, state, and local requirements. Develops and maintains case management policies and procedures. Coordinates, directs, and performs concurrent and retrospective reviews, 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 as needed for outside services for patients/families. Consults with physicians, health care providers, discharge planning and outside agencies regarding continued care/treatment or hospitalization. Encourages members to follow plans of care (e.g., drug therapy, physical therapy). Makes referrals to appropriate community services. Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum. Develops and collects data, and 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. OTHER DUTIES: Under the supervision and direction of the Chief of Nephrology, and in collaboration with and UCD Transplant Medical Director, coordinates post-operative outpatient management and outpatient long-term follow-up. The Transplant Coordinator coordinates pre-transplant evaluation, and monitors, evaluates and reports post-transplant organ function and complications for the transplant recipient. The Coordinator coordinates pre-transplant evaluation; and post-transplant follow-up care, monitors patient status, and facilitates the physical, social and emotional rehabilitation of the patient. Provides post-transplant teaching to the recipient and family. Assesses and monitors post-operative organ function, lab values, diagnostic tests, and patient symptoms/concerns and reviews finding with physician. Monitors for potential medical, surgical and immunologic complications, medication side effects, emotional maladjustments, and long-term problems such as chronic rejection, recurrent disease, and malignancy. Provides long-term follow up that includes monitoring compliance with the medical plan of treatment including medication administration, and laboratory studies, and clinic visits as prescribed intervals. Assesses patient’s response to treatments and procedures and consults with physician regarding need for medication adjustments, additional laboratory studies, or consultation with other healthcare professionals. Assesses patient’s social and emotional needs, and identifies goals for long term rehabilitation, including referral to support groups and counseling as needed. Confers with physician and determines interventions. Provides education to the patient and family regarding frequency of visits and laboratory tests, medications, reporting abnormalities, signs and symptoms of rejection, and diagnostic procedures. Assesses and triage changes in patient status and response to treatment and procedures:  Review patient medications and make adjustments as prescribed; Determine need and arrange for laboratory studies, diagnostic procedures and consults Evaluate compliance with medical plan Assess patient’s physical, social, and emotional needs Establishes rapport and maintains effective communication with patients, families and other healthcare professionals Updates own knowledge of transplantation; keeps abreast of developments in related areas of medicine and nursing.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 licenser requirements (if applicable), and Kaiser Permanente’s policies and procedures.  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. PLEASE NOTE:  - Kaiser Permanente is an AA/EEO employer – Additional Information Reference Code: Patient Care Coordinator / Transplant coord - 526 Position Type: Full Time, Employee