Continuum Care Case Manager

Coordinates and supports transition care activities for members moving from the emergency department or inpatient hospital setting to alternative settings of care, including home health, skilled nursing facility, hospice, durable medical equipment, home-based services, and other community-based resources. Works collaboratively with hospital-based teams, including case management, social work, utilization management, physicians, nursing staff, and contracted service providers to identify members with complex discharge needs and operationalize safe, timely, and appropriate discharge pathways. Serves as a resource and liaison to help reduce barriers to discharge, avoid unnecessary inpatient admissions when appropriate, and support successful transitions of care across the continuum.

• Provides leadership and direction to contract service providers. Develops and implement systems and models of care to ensure high quality, cost-effective outcomes for programs within areas of responsibility.
• Defines and assesses problems; develops and implements solutions for providers, staff, and contract service providers for aggregate populations. Provides professional consultation for complex situations to internal providers, staff, members and community service agencies.
• Acts as primary liaison among contract service providers, members and Kaiser Permanente systems. Develops and implements programs for changing organization and member needs.
• Works alongside emergency department and hospital-based staff, including case management, social work, utilization management, physicians, nurses, and ancillary teams, to identify members who may be appropriate for alternative disposition or require support for complex discharge pathways.
• Supports the development and operationalization of discharge plans from the emergency department and inpatient hospital setting to alternative settings of care, including home health, skilled nursing facility, hospice, durable medical equipment, outpatient follow-up, home-based services, and community resources.
• Serves as a liaison between hospital teams, Kaiser Permanente care teams, contracted providers, health plan resources, members, families, and caregivers to coordinate timely transitions of care and resolve barriers to discharge.
• Assists with coordination of complex discharge needs, including confirming service availability, facilitating referrals, submitting authorization requests, supporting communication with contracted vendors, and ensuring necessary information is shared to support safe and timely placement or service initiation.
• Identifies and escalates barriers that may delay discharge or prevent appropriate alternative disposition, including gaps in benefit coverage, transportation needs, post-acute service availability, durable medical equipment needs, caregiver limitations, or clinical follow-up requirements.
• Tracks and documents transition care activities, referral status, barriers, outcomes, and follow-up needs in appropriate systems to support continuity of care, program evaluation, quality improvement, and reporting.

• Minimum two (2) years of experience in care coordination, planning, or patient care delivery in home health, long-term care, skilled nursing, rehabilitation, acute care, public health, or hospital discharge planning.

• Bachelors degree in healthcare, social work, or a related field OR four (4) years of experience in in a directly related field.
• High School Diploma or General Education Development (GED) required.

• National Provider Identifier required at hire

• Knowledge of hospital discharge planning, home health and community-based resources, skilled nursing and hospice services, and Medicare and Medicaid guidelines.
• Strong facilitation, conflict resolution, and negotiation skills

• Masters degree in healthcare, social work, or a related field
• Health profession credentials including RN, LCSW, Physical Therapist, Occupational Therapist, or similar health specialty.