RN Case Manager Liaison Nurse - Discharge Planning

**  SIGN-ON BONUS OF $5,000 APPLIES TO ELIGIBLE EXTERNAL HIRES!   ** RN CASE MANAGER LIAISON NURSE - INPATIENT DISCHARGE PLANNING - ONSITE:  OVERLAKE - BELLEVUE VARIABLE MON-FRI  -  8AM-4:30PM  -  EVERY OTHER WEEKEND ROTATION - ROTATING HOLIDAYS AMONG TEAM Job Summary: The Care Manager will work in two 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. Essential 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). Evaluate ability and availability of designated caregiver(s) to provide patient support. 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. Continuously update needed services. 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. 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. 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. Basic Qualifications: Experience Minimum three (3) years of recent RN medical/surgical/ambulatory clinical experience required. Minimum two (2) years of RN experience in ambulatory case management, care coordination or disease management. Education Bachelors degree License, Certification, Registration Registered Nurse License (Washington) required at hire OR Compact License: Registered Nurse required at hire Basic Life Support required at hire Case Manager Certificate within 36 months of 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. Bachelors of science in nursing. Primary Location: Washington,Bellevue,Overlake Hospital Medical Center Additional Locations: Washington Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 08:00 AM Working Hours End: 04:30 PM Job Schedule: Full-time Job Type: Standard Worker Location: Onsite Employee Status: Regular Employee Group/Union Affiliation: J01|SEIU|SEIU Local 1199 RN/ANRP Job Level: Individual Contributor Department: Renton Admin Baker - UR-Discharge Planning - 1130 Pay Range: $48.57 - $81.9 / hour Travel: No On-site: Work location is on-site (KP designated office, medical office building or hospital). Worker location must align with Kaiser Permanente's Authorized States policy. Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status. Submit Interest Save Job Expected Employee Conduct > Back to nav Share This Job Facebook (Opens in new tab or window) X (Opens in new tab or window) LinkedIn (Opens in new tab or window) Email (Opens in new tab or window) Navigating the Hiring Process We're here to support you! Having trouble with your account or have questions on the hiring process? Please visit the FAQ page on our website for assistance. Need help with your computer and browser settings? Please visit the Technical Information page for assistance or reach out to the web manager at kp-hires@kp.org . Do you need a reasonable accommodation due to a disability? 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• 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).
• Evaluate ability and availability of designated caregiver(s) to provide patient support.
• 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.
• Continuously update needed services.
• 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.
• 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.
• 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.

• 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.

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• Career Growth & Development

At Kaiser Permanente our nurses are leaders, clinicians, researchers, innovators, and scientists who are contributing toward being an industry-leading voice for advancing evidence-based care. Whether supporting the patient directly in our hospitals or clinics, providing care at home, serving our patients through innovative virtual technology, or managing care delivery teams, Kaiser Permanente nurses utilize scientific evidence and our integrated care model to optimize the total health of our members and the communities we serve. We invite nurses who are passionate about nursing excellence, high-quality compassionate care delivery, professionalism, integrity, teamwork and patient and family centeredness to join our teams so that we can continue to sustain and build upon our culture of excellence. At Kaiser Permanente, we cultivate an environment of compassion, integrity, trust, and open communication that helps our teams do their best work. We believe that lifelong learning will expand our knowledge so we can better serve our patients. Our practice is rooted in research and evidence-based care. Our nurses reflect the rich diversity of our members and communities and provide culturally responsive and competent care that promotes understanding of our members needs and preferences. At Kaiser Permanente, nurses are highly skilled professionals who exemplify leadership, critical thinking, and collaborative problem solving and deliver the right care, at the right time, in the right setting.