RN Liaison Nurse No Weekends SNF Hybrid Olympia Position

4 weeks ago

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

The Care Manager will work in 2 settings on a periodic rotating schedule, planning the discharges and follow up care for Kaiser Foundation Health Plan of Washington patients hospitalized at a nearby network facility and carrying a case load of patients in one of the Kaiser Foundation Health Plan of Washington medical centers. Some weekends and holidays are required, and scheduled days of the week are variable. Primary responsibility is to focus on achievement of optimal patient health care outcomes while ensuring appropriate utilization of health care resources. Working closely with primary care teams, specialty care teams and medical providers, the Liaison Nurse will establish a collaborative plan of care to assure adherence to the medical plan, improvement in functional status, and improved ability to self-manage. Serves as the liaison across the internal KFHPW care continuum and between KFHPW and all externally contracted providers, facilities, and resources and provides feedback to the organization regarding the service and quality of contracted services. The Liaison Nurse collects data and provides input to leadership regarding issues or concerns related to utilization, cost, quality, service and care delivery to patients.


Key Responsibilities:
  • Ensures patients referred to case management meet established case management criteria.
  • Assesses all patients referred for case management to determine physical, mental, financial, psychosocial status, utilizing comprehensive, standardized criteria to identify existing and potential needs.
  • Develops patient-centered case management plans based on assessments and including patient goals, objectives, and outcomes with specific time frames (long/short term).
  • Evaluates ability and availability of designated caregivers to provide patient support.
  • Coordinates and implements interventions using evidence-based guidelines.
  • Recommends additional services to primary care physicians as determined in the case management plan.
  • Conducts ongoing assessments of progress against original goals.
  • Continuously updates needed services.
  • Maintains ongoing communication with patients/families and care teams.
  • Acts as an advocate for patient care needs.
  • Documents all responses of patients to case management interventions.
  • Collaborates with other healthcare professionals regarding the plan of care, variances in plan implementation, achieved outcomes or expected outcomes.
  • Monitors and evaluates short- and long-term patient responses to therapeutic interventions and analyzes patterns of variance from clinical information and outcomes.
  • Recommends alternative settings for care based on healthcare needs and appropriate utilization of healthcare resources.
  • Documents interventions and interactions with patients or caregivers according to KFHPW and Care Management policy and procedure.
  • Participates in the measurement of the effectiveness of the case management program.
  • Directs and guides the plan of care to result in a seamless continuum of care.
  • Facilitates referrals for home health care, long-term care, hospice, and other care facilities or services as needed.
  • Participates in care conferences to provide problem-solving for patients with complex care needs (limited basis).
  • Collects data needed to evaluate the effects of care coordination on quality outcomes, fiscal parameters, patient satisfaction, and systems improvement.
  • Understands and utilizes health plan requirements and patient benefits in making care management decisions.
  • Assists patients in understanding and complying with their medical treatment plans.
  • Supports patient education and activation through referrals to specific chronic illness classes, group visits, or community resources.
Requirements:
  • Minimum three (3) years of recent RN medical/surgical/ambulatory clinical experience required.
  • Bachelor's degree or Bachelor's of Science in Nursing required.
  • Registered Nurse License (Washington) required at hire OR Compact License: Registered Nurse required at hire.
  • Case Manager Certificate within 24 months of hire.
  • Basic Life Support required at hire.
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 preferred.

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