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RN Liaison Nurse
2 months ago
The Care Manager will work in two healthcare settings on a rotating schedule, planning discharges and follow-up care for patients hospitalized at a nearby network facility and managing a caseload of patients in one of the Kaiser Permanente medical centers.
This role requires working some weekends and holidays, with variable scheduled days of the week. The primary responsibility is to focus on achieving optimal patient healthcare outcomes while ensuring appropriate utilization of healthcare resources.
Key Responsibilities:- Ensure patients referred to case management meet established criteria.
- Assess patients referred for case management to determine their physical, mental, financial, and psychosocial status, utilizing comprehensive and standardized criteria to identify existing and potential needs.
- Develop patient-centered case management plans based on assessments, including patient goals, objectives, and outcomes with specific time frames.
- Evaluate the ability and availability of designated caregivers to provide patient support.
- Coordinate and implement interventions using evidence-based guidelines.
- Recommend additional services to primary care physicians as determined in the case management plan.
- Conduct ongoing assessments of progress against original goals.
- Continuously update needed services.
- Maintain ongoing communication with patients, families, and care teams.
- Act as an advocate for patient care needs.
- Document all responses of patients to case management interventions.
- Collaborate with other healthcare professionals regarding the plan of care, variances in plan implementation, achieved outcomes, or expected outcomes.
- Monitor and evaluate short- and long-term patient responses to therapeutic interventions and analyze patterns of variance from clinical information and outcomes.
- Recommend alternative settings for care based on healthcare needs and appropriate utilization of healthcare resources.
- Document interventions and interactions with patients or caregivers according to Kaiser Permanente and Care Management policy and procedure.
- Participate in the measurement of the effectiveness of the case management program.
- Direct and guide the plan of care to result in a seamless continuum of care.
- Facilitate referrals for home healthcare, long-term care, hospice, and other care facilities or services as needed.
- Participate in care conferences to provide problem-solving for patients with complex care needs.
- Collect data needed to evaluate the effects of care coordination on quality outcomes, fiscal parameters, patient satisfaction, and systems improvement.
- Understand and utilize health plan requirements and patient benefits in making care management decisions.
- Assist patients in understanding and complying with their medical treatment plans.
- Support patient education and activation through referrals to specific chronic illness classes, group visits, or community resources.
- Minimum three years of recent RN medical/surgical/ambulatory clinical experience required.
- Bachelor's degree or Bachelor's of Science required.
- Registered Nurse License (Washington) required at hire.
- Compact License: Registered Nurse required at hire.
- Case Manager Certificate within 24 months of hire.
- Basic Life Support required at hire.
- Minimum two years of RN experience in utilization review, ambulatory case management, care coordination, or disease management.
- Bachelor's of Science in Nursing.
