The LVN/LPN Case Manager Assistant is responsible to conduct medical necessity screening and work collaboratively with the interdisciplinary team to provide care coordination for patients under the direction of a Registered Nurse and in compliance with evidence-based practice and regulatory requirements. This position complies with the scope of services defined by the Licensed Vocational /Practical Nurse LVN/LPN state licensure requirements. This position integrates national standards for case management scope of services including: Utilization Management supporting medical necessity and denial prevention, Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care, Compliance with state and federal regulatory requirements, TJC accreditation standards and policy Education provided to physicians, patients, families and caregivers, and other duties assigned.Essential Responsibilities:The individual’s responsibilities include the following activities: a) accurate medical necessity screening and submission for Physician Advisor review b) care coordination, c) implementation of the transition plan based on RN Case Manager and/or Social Worker (SW) assessment(s), d) communication with interdisciplinary team during patient care conferences, e) management of concurrent disputes, f ) communication with patients and families regarding the plan of care established by RN, SW and Physician, g) collaboration with physicians, office staff and ancillary departments, h) clear, complete and concise documentation in electronic system, i) maintenance of accurate patient demographic and insurance information, j) identification and documentation of potentially avoidable days, k) identification and reporting of over and underutilization , l) and other duties as assignedUtilization Management:Assures the patient is in the appropriate status and level of care based on Medical Necessity process and submits for Secondary Physician review per Kaiser policyEnsures timely communication of clinical data to various payers to support admission, level of care, length of stay and authorization for post-acute servicesAdvocates for the patient and hospital with payers to secure appropriate payment for services renderedCompletion of clinical reviewsPromotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomesIdentifies and documents Avoidable Days using the data to address opportunities for improvementPrevents denials and disputes by communicating with payers and documenting relevant informationCoordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post- acute care) supported by evidence-based practice, internal and external requirements.Identifying appropriate level of care needsAssisting with patient transition to the appropriate level of careOrder clarification admission status and patient classification.Maintain and foster timely and accurate with all members if the multidisciplinary team.Escalates barriers to patient care as appropriateOther duties assigned.(30% daily, essential).Transition Management:Makes referrals for post-acute services based on needs identified by the RN Case Manager or SW staff assessment and utilizing the electronic Case Management systemProvides patients and families with choices of post-acute providers per Kaiser policy.Based on SW and RN assessment and plan follows up on readmitted patients and implement strategies to address opportunities outlined.Ensures all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post-acute providers.Identifies and reports variances in appropriateness of medical care provided, over/under utilization of resources compared to evidence-based practice and external requirements. This priority includes documentation in the Case Management system to communicating information through clear, complete and concise documentation(30ily, essential)Care Coordination:Follows up on patients identified by the SW and /or RN Case Manager on factors that may affect the progression of careEnsures consults, testing and procedures are sequenced to support the patients clinical needs with timely and efficient care deliveryEnsures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of careEffectively collaborates with physicians, nurses, ancillary staff, payors, patients and families to achieve optimum clinical and transition outcomes.(15% daily, essential).Education:Contributes to the education to patients and the care team relevant to theEffective progression of care,Appropriate level of care, andSafe and timely patient transitionProvides patients and healthcare team information regarding resources and benefits available to the patient along with the economic impact of care optionsEnsures that education has been provided to the patient/family/caregiver by the healthcare team prior to discharge(15% daily, essential).Compliance:Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of servicesAdheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Kaiser policies.Operates within the LVN/LPN scope of practice as defined by state licensing regulationsRemains current with Kaiser Utilization Management/Case Management practices(10% daily, essential)PRIMARY INFORMATION, TOOLS AND SYSTEMS USED:Patient data – hospital admission, discharge, transfer systemHealthcare staff documentation related to patient careRegulatory and payor requirementsKaiser Plan benefitsHealth ConnectTapestryMcKesson Care Enhance Review Manager (CERMe) InterQual systemClinical data interface and secure faxingPatient Medical Record including Health Connect and TapestryHospital specific Clinical SoftwarePERFORMANCE METRICS AND EVALUATION:The metrics below provide an indication of the effectiveness of the individual in this role and may be used for evaluative purposes. The list below is not meant to be exhaustive; other relevant metrics may exist.InterQual reviewsObservation hoursExcess Days/ALOSPatient Day RateIQM metricsNumber and type of avoidable daysResource UtilizationSUPERVISORY RESPONSIBILITIES:NoneBasic Qualifications:ExperienceMinimum two (2) years of hospital or ambulatory or post-acute experience.EducationHigh School Diploma or General Education Development (GED) required.License, Certification, RegistrationActive LVN/LPN nursing licenseAdditional Requirements:Skills required include excellent organizational skills, excellent verbal and written communication skills, demonstrated problem solving skills, and computer literacy.Must complete InterQual test and pass with a score of 85 or better within 60 days of hire and annually.Must complete and demonstrate competency in using the Kaiser/Utilization Management/Case Management documentation system within 60 days of hire.Attendance at hospital and department orientation is required.Department orientation includes review and instruction regarding Utilization Management/Case Management, Compliance policies, InterQual, Transition Management, and other topics specific to case management.Preferred Qualifications:Hospital Case Management experience preferred.Active RN license preferred.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.External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.COMPANY: KAISERTITLE: LVN/LPN Case Manager AssistantLOCATION: Los Angeles, CaliforniaREQNUMBER: 944194External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.