RN Liaison Nurse No Weekends SNF Hybrid Olympia

4 weeks ago

Seattle, Washington, United States Kaiser Permanente Full time
Job Summary:

The Care Manager will work in a dynamic environment, collaborating with healthcare teams to plan discharges and follow-up care for patients hospitalized at a nearby network facility. This role requires a strong focus on achieving optimal patient health care outcomes while ensuring appropriate utilization of healthcare resources.

As a Liaison Nurse, you will work closely with primary care teams, specialty care teams, and medical providers to establish a collaborative plan of care. This will involve ensuring adherence to the medical plan, improving functional status, and enhancing patient self-management.

You will serve as a liaison across the internal Kaiser Permanente care continuum and between Kaiser Permanente and externally contracted providers, facilities, and resources. This will involve providing feedback to the organization regarding the service and quality of contracted services.

The Care Manager will collect data and provide input to leadership regarding issues or concerns related to utilization, cost, quality, service, and care delivery to patients.

Essential Responsibilities:
  • Ensure patients referred to case management meet established case management criteria.
  • Assess all patients referred for case management to determine physical, mental, financial, psychosocial status, utilizing comprehensive, standardized criteria to identify existing and potential needs.
  • Develop patient-centered case management plans based on assessments and including patient goals, objectives, and outcomes with specific time frames (long/short term).
  • Evaluate ability and availability of designated caregivers to provide patient support.
  • Coordinate and implement interventions using evidence-based guidelines.
  • Recommend additional services to PCPs as determined in the case management plan.
  • Conduct ongoing assessment of progress against original goals.
  • Continuously update needed services.
  • Maintain ongoing communication with patient/family and care team.
  • Act as an advocate for patient care needs.
  • Document all responses of patient 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 as needed, referrals for home health care, long-term care, hospice, and other care facilities or services.
  • Participate in care conferences to provide problem-solving for patients with complex care needs (limited basis).
  • Collect needed data 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 to understand and comply with their medical treatment plan.
  • Support patient education and activation through referral to specific chronic illness classes, group visits, or community resources.
Basic Qualifications:
  • Minimum three (3) years of recent RN medical/surgical/ambulatory clinical experience required.
Education:
  • Bachelor's degree or Bachelor's of Science.
License, Certification, Registration:
  • Registered Nurse License (Washington) required at hire OR
Compact License:
  • Registered Nurse required at hire
Additional Requirements:
  • Effective, independent nursing judgment and skills, and use of evidence-based clinical decision-making criteria.
  • Knowledge in management of chronic disease process, nursing process, and collaborative care planning.
  • Demonstrated skill and experience in effectively collaborating with care team members.
Preferred Qualifications:
  • Minimum two (2) years of RN experience in utilization review, ambulatory case management, care coordination, or disease management.
  • Bachelor's of Science in Nursing.

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