Under indirect supervision and in collaboration with physicians, coordinates case management for members residing in community long-term care facilities. Provides and ensures high quality care to include assessment, evaluation, development, facilitation, and implementation of individualized plans of care. Collaborates with health care team, patient, family, and caregivers to assure safe, agreeable, and appropriate patient plan of care. Provides consultation and education to other health care providers. Collaborates with special work teams in developing programs to support efficient continuity of care for high risk members. Provides consultative and clinic nurse specialist/nurse practitioner services for homecare patients. As member of Geriatric Long-Term Care Team, collaborates with physicians in providing direct primary, secondary, and tertiary care services in outpatient, home, inpatient, and community settings with emphasis on long-term care arena. Liaisons between members/families, clinics, hospitals, and selected long term care facilities.
Essential Functions:
- Provides primary care and case management to panel of members residing in selected long-term care facilities which include intake assessment, evaluation, development of individualized plan of care, annual physical exam, timely certifications, and recertification's, routine follow-up visits, and urgent visits in collaboration with physician to assess, diagnose, and implement therapeutic plans of care including prescribing medications, wound care, and debridement within scope of practice
- Orders and monitors appropriate laboratory, radiology, and other diagnostic tests; educates patient and family about health status, prognosis, and treatment choices
- Encourages and documents advanced directives clarifications
- Provides consultation and direct care to complicated geriatric inpatient, outpatient, and home care patients upon referral from physicians or home health nursing staff
- Participates as member of Geriatric and Long Term Care team in program development, quality assurance, and quality improvement processes
- Documents all care provided to patients including observations, treatments, medications, and instructions according to Regional and/or facility standards; documents all communications and medical orders; assures clinical record is accurate, legible, and complete; completes Kaiser visit logs and required encounter data in timely manner
- Works collaboratively with hospitals, clinics, and community sites in program development, and development of policies, procedures, quality assessment, and improvement indicators for these programs
- Identifies needs and coordinates in-service programs, workshops, and seminars; actively participates in educational program planning, development, presentation, and evaluation
- Participates in patient care conferences with other health care team members to coordinate, discuss, and evaluate services provided to patient
- Acts as liaison with and handles facility/family concerns related to long-term care; identifies and reports potential problems to appropriate Kaiser Permanente representatives
- Participates in department functions such as staff meetings, staff in-services, and committees as assigned
- Participates in quality assurance/quality improvement activities as assigned
- Additional essential functions as listed in the complete job description
Qualifications:
Basic Qualifications:
- Five years of direct patient care experience as RN with two years as Clinical Nurse Specialist or Nurse Practitioner
- One year of experience working with geriatric patients and community agencies dealing with same
- Master's degree in nursing with specialty in gerontological, adult, family, or acute care
- Valid Hawaii RN License (must meet education requirement(s) for Hawaii State licensure)
- Valid Hawaii APRN Recognition (must meet education requirement(s) for Hawaii State recognition)
- Certified Nurse Practitioner or Clinical Nurse Specialist in gerontological, adult, family, or acute care as accepted by the Hawaii State Board of Nursing
- Current BLS for Healthcare Provider CPR or CPR/AED for the Professional Rescuer certification
- Valid driver's license
- National Provider Identifier (NPI) and Taxonomy code required at time of hire
- Demonstrated knowledge of and skill in oral communication, written communication, teamwork, group process facilitation, interpersonal relations, customer service, and problem solving
- Talking to co-workers, customers, outside vendors, and on the telephone
- Reading, writing, speaking, and understanding English
- Training/giving and receiving instructions
- Mathematical ability, attention to detail (e.g. organization, prioritization, proofing), concentration, and alertness
- National Provider Identifier (NPI) and Taxonomy code required at time of hire
Preferred Qualifications:
- Valid Hawaii APRN Recognition with Prescriptive Authority (must meet education requirement(s) for Hawaii State APRN prescriptive authority)
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.