RN Case Manager Liaison Nurse

5 days ago

Bellevue, 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.

Key Responsibilities:
  • Ensures 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 plan based on assessments and including patient goals, objectives, and outcomes with specific time frames (long/short term).
  • Coordinate and implement interventions using evidence based guidelines.
  • Recommend additional services to PCP as determined in the case management plan.
  • Conduct ongoing assessment of progress against original goals.
  • Maintain ongoing communication with patient/family and care team.
  • Acts as an advocate for patient care needs.
  • Documents all responses of patient to case management interventions.
Collaboration and Communication:
  • Collaborates with other health care 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 health care needs and appropriate utilization of health care resources.
  • Document interventions and interactions with patients or caregivers according to KFHPW and Care Management policy and procedure.
  • Participate in the measurement of the effectiveness of the case management program.
Leadership and Guidance:
  • Directs and guides the plan of care to result in a seamless continuum of care.
  • Facilitates as needed, referrals for home health care, long term care, hospice, and other care facilities or services.
  • Participation in care conferences to provide problem solving for patients with complex care needs (limited basis).
  • Collects needed 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 patient to understand and comply with their medical treatment plan.
  • Supports patient education and activation through referral to specific chronic illness classes, group visits or community resources.
Requirements:
  • Minimum three (3) years of recent RN medical/surgical/ambulatory clinical experience required.
  • Bachelors degree or bachelors of science required.
  • Registered Nurse License (Washington) required at hire.
  • Basic Life Support required at hire.
  • Case Manager Certificate within 24 months of hire.

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