The RN Case Manager functions in a self-directed role with a high degree of autonomy in an expanded clinical role guiding appropriate use of resources for a variety of chronic conditions. RN Case Management Services will have accountability for a designated population defined in conjunction with the clinicians in the medical home, and assists the organization in meeting regulatory service and care needs for these populations. The RN Case Manager works collaboratively as a member of the health care team to deliver high quality health care to patients supporting Kaiser Permanente's mission, vision and values. The RN Case Manager provides a variety of nursing services both in person, by phone and via electronic media utilizing nursing process and leadership skills to address acute and chronic needs of Health Plan members and other patients of the Kaiser Permanente Health Care Program. He/she works under the general direction of the designated supervisor and may function in multiple settings within the system, the community and home to provide support for a high risk population.
Essential Functions:
- Utilize regional population stratification information and processes to identify appropriate members for enrollment into case management in collaboration with clinicians and health care team members of the medical home.
- Independently and proactively complete chart reviews, screening calls and full assessments related to the anticipated level of care and document findings using standardized approved documentation tools.
- Triage findings from member assessments, identifying needs and issues, engage patients to define a plan of care and appropriate level of self-management and interventions.
- Determine Level of Care.
- Communicate findings and actions to involved care providers through succinct summaries that include findings, actions and further recommendations.
- With the member/family and appropriate KP staff and providers, develop and document a patient-centered care plan that addresses short term goals that are specific, attainable and measurable.
- Provide care coordination and management services for members with identified needs: Creatively using available and appropriate resources, including KP staff and providers, to support the unique needs of each member.
- Facilitating access to internal and external services.
- Monitoring the effectiveness of the interventions.
- Reinforcing the treatment plan through life-style, diet and medication adherence including support for Chronic Condition therapies and Opiate Therapy Plan adherence.
- Advising and coaching patients and families.
- The RN Case Manager is the touch point for initiation and ongoing oversight of patient care for Hepatobiliary/Surgical Oncology patients in the General Surgery department.
- The majority of their work will focus on approving and coordinating referrals, initial surgical planning, pre and post-operative care.
- The CM will assist in refocusing of care at any time the patient feels they have lost their direction in the implementation of the overall care plan.
- The CM will coordinate the navigation of the individual for the entire course of their care and they will remain a resource for the individual patient for the remainder of their care across the continuum.
- The CM will develop and teach classes related to pre and post-operative care to both patients and co-workers
- The CM will maintain tracking database, from pre-authorization through life-long post-op follow-up.
- The CM will monitor and evaluate quality and effectiveness of care strategies for this patient population.
- This job description is not all encompassing.
Qualifications:
Basic Qualifications:
- Minimum six (6) years of experience in acute care or ambulatory care/clinic/extended setting within the last eight (8) years.
- At least two (2) years of experience working with patients with liver disease &/or complex cancers.
- Demonstrate and maintain knowledge and experience working with cancer patients to navigate through the care continuum.
- Graduate of Accredited School of Nursing.
- Bachelor of Science in nursing or equivalent nursing experience (six (6) plus years), with the priority given to case management and/or care coordination.
- Current RN license in Oregon and Washington. Requires Oregon or Washington license at time of hire. Licenses in both states are required within six (6) months of hire.
- Valid driver's license.
- Current BLS w/AED certification.
- Able to type 20 words per minute.
- Knowledge of case management principles.
- Demonstrates clinical nursing and leadership skills.
- Ability to work independently in an unstructured environment with minimal supervision
- Demonstrates effective interpersonal, communication and problem-solving skills.
- Willingness to learn computerized information systems.
- Demonstrates ability to work within teams and within a dynamic work environment.
- Demonstrates customer-focused service skills.
- Knowledge of community resources for the care of the elderly, and patients with chronic conditions.
- Demonstrated ability to organize, coordinate, and manage care plans.
- Thorough knowledge of levels of care within outpatient, acute care, and extended care settings.
- Demonstrated ability to work as part of a multidisciplinary team.
- Effective written and verbal communication skills.
- Ability to present reports verbally in a public setting (public speaking).
- Demonstrated data entry skills and ability to use Microsoft Word software.
- Must have knowledge of adult case management practices.
- Demonstrate and maintain knowledge of current Complex Surgical practice.
- Appropriately apply evidence-based protocols
- Knowledge of community resources for this patient population.
- Must have competent teaching skills with individuals or small groups
- Demonstrate and maintain knowledge of Complex Cancer and Liver Disease population, as well as pre and post-surgical care.
- Thorough assessment skills, recognize barriers to care, able to assess current motivation and self-care (or care giver) management skills, able to identify knowledge gaps.
- Strong critical thinking skills.
- Must have good computer skills, triage knowledge and have the ability to work independently.
- Must be very detailed oriented.
- Must be able to meet designated deadlines and accomplish set goals.
- Must display exceptional Customer Service Skills, professionalism and strong organizational skills.
- Must be able to work in a team environment under the direction of one, or more, Surgical Providers.
- Must have competent patient and team engagement skills.
- Must have competent teaching skills with individuals or small groups.
Preferred Qualifications:
- Previous experience with population care/case management, triage and advice preferred.
- Prefer at least two (2) years of experience in case management, care coordination, or population care preferred.
- Prior experience with care/case management, triage and advice for surgical population preferred.
- Prior experience and skill with telephonic patient assessment preferred.
- Experience working from standardized policies and procedures preferred.
- Quality management methodology and utilization management experience preferred.
- Microsoft Word, Excel, and HC experience preferred.
- Current or future bachelor's degree in nursing or a related field preferred.
- Certified Case Manager preferred.
- Certification in Hepatobiliary Disease preferred.
Salary Range:
$33.10 - $47.60
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.