The Complex Case Manager is a Nationally Board Certified Professional. He/she is responsible for performing all activities on members referred to the complex case management program. This includes a comprehensive clinical evaluation, assessment and documented care plan in all domains including social determinants of health, psycho-social, financial, medications, ADL/IADLs and cognitive, coordinating and monitoring all services needed with a focus on providing education and the goal of self-management skills. Additional responsibilities include ensuring continuity of care through interaction and team- work with the Inpatient Case/Care Managers, Transition of Care staff, QRM staff, Population Care staff, Medical Office staff, Social Workers, Vendors and other KPGA staff. Educates Providers, member and caregivers and the promotion of quality care and a high level of member and/or caregiver satisfaction. The Complex Case Manager will ensure work demonstrates adherence to NCQA Standards of Excellence.

• Reviews all referrals to the Complex Case Management Programs within designated timeframe per policy and procedure and evaluate for case management based on established guidelines to ensure compliance with NCQA standards. This includes the preliminary evaluation of benefits within KPGA and community resources available.
• Performs a thorough and objective assessment of the member including physical, psychosocial, environmental, financial, and health status expectation through the use of EMR and hospital records, contact with the member, significant others, caregivers and current medical caregivers (if permitted by the member).
• Obtains consent from the member/caregiver for participation in Complex Case Management.
• Develops a comprehensive plan of care based on the assessment and in conjunction with the treating practitioner, identifies specific interventions, objectives, and goals with anticipated targeted dates for member accomplishment and self-management.
• Communicates the plan of care to the member/caregiver and provides education to the regarding the members condition as necessary.
• Implements the plan of care and specific interventions that will lead to the accomplishment of goals as defined in the plan of care.
• Establishes specific dates for follow-up and assesses the members status and progress toward the established goals and adjusts the plan of care as necessary.
• Performs referrals to other KPGA programs and coordinate referrals to community resources necessary to accomplish the goals and makes recommendations for modifications to the plan of care as necessary.
• Continuously evaluates and monitors all activities and/or services provided through the case management plan to determine the effectiveness of the plan.
• Documents all case management interactions and interventions according to guidelines including any pertinent patient information or arrangements in the members medical record.
• Identifies and Evaluates expected outcomes, utilization of services and associated costs of the plan of care as well as any proposed alternative plan of care and makes the necessary revisions.
• Coordinates and participates in case conferences on a regular basis with all Providers involved in the care and updates the plan of care as necessary.
• Continuously coordinates, monitors, tracks and evaluates all care and services rendered to ensure that quality care is being delivered in the most appropriate setting.
• Assists in the development and implementation of Continuous Quality Improvement (CQI) projects.
• Works closely with the member and practitioner to ensure that the most appropriate and cost- effective services are always provided to the member while maintaining quality outcomes.
• Performs hospital discharge follow up on assigned population. Arranges, coordinates, and facilitates appointments for the member as necessary.
• Maintains effective interaction/communication with members, nursing staff, inpatient care coordinators, the transitional review team, social workers, general reviewers, referral coordinators, and Kaiser Permanente medical offices to facilitate the case management process and to provide continuity of care.
• Identifies the need for discharge from the Case Management Program based on defined goals and criteria, and discharges the member after notifying the member and practitioner as well as any other resources such as the Social Worker, Transitional Review Team, etc.
• Performs as an integrated health care team member, providing continual education to HCT staff as to role and responsibilities in care coordination. Remains accessible to the HCT and attends all HCT meetings as appropriate.
• Collaborates effectively with Providers and other departments within the health plan by acting as a resource to TSPMG Providers, contracted consultants, Health Plan administrators and medical office staff and other departments within the organization.
• Provides case management updates to Providers and health care teams.
• Performs home visits as appropriate for members in case management.
• Knowledgeable and compliant with regional personnel, unit specific and departmental policies and procedures. Assists in the development of department protocols as needed.
• Participates in annual regional and departmental compliance training.
• Knowledgeable and compliant with Principles of Responsibility.
• Consistently supports compliance and the Principles of Responsibility (Kaiser Permanentes 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 Permanentes policies and procedures.
• Access to protected health information (PHI) will be limited to the minimum necessary required to effectively perform the job.
• Demonstrates understanding of HIPAA privacy regulations by maintaining confidentiality of Protected Health Information (PHI).
• Demonstrates doing the right thing and doing things the right way is an underlying premise in all work- related activities and is able to identify location of copy of Principles of Responsibility.
• Develops and maintains an awareness of how to report compliance issues and concerns. Identifies issues of wrong- doing and promptly investigates and reports to immediate supervisor or Director of Regional Compliance. Serves as a primary contact person between the medical offices and community agencies as it relates to coordinating and facilitating the appropriate level of care and provision of services.
• Collaborates with the social worker to provide information to members and HCTs regarding community resource referrals.
• Remains knowledgeable of contract benefits and current, industry utilization trends relevant state and Federal regulations, criteria, documentation requirements (including Medicare and HCFA) and laws that affect managed care and case/utilization management.
• Investigates, identifies and reports problems and inefficiencies in existing systems, and recommends changes when appropriate to the Team Leader and/or Manager.
• Under the guidance of the Team Leader and in consultation with other QRM and IQM staff, participates in the coordination, planning, development, implementation, and maintenance of all Complex Case Management Program department policies and procedures.
• Reviews the statistics of case management interventions with the Supervisor/Team Leader and adjusts based on findings.
• Performs quality of care and service reviews using identified quality indicators and refers cases identified as risk management, peer review or quality issues to Quality and Risk Management.