Acts as medical liaison between at risk/frail elderly patient, family, community resources, staff and medical staff/providers. Provides continuity of care to patient by coordinating care and services needed in all settings in continuum of care. Functions as a Case Manager for at risk/frail elderly patients. Develops, coordinates and monitors programs and care plans relating to patient care. Provides ongoing communication with health care providers. Assists with process improvement. Serves as a resource to patients, families, caregivers, physicians, staff and community providers. Facilitates access to care.
Essential Functions:
- Acts as medical liaison between at risk/frail elderly patient, family, community resources, staff and medical staff/providers. Provides continuity of care to patient by coordinating care and services needed in all settings in continuum of care.
- Develops, coordinates, implements and monitors population based activities/programs and plan of care to meet Regional goals, customer needs and regulatory requirements. Provides ongoing communication with health care providers.
- Provides case management services for at risk/frail elderly patients to insure quality of care using an interdisciplinary approach. Participates with providers to implement strategies to achieve established outcomes and goals of care. Formulates and coordinates comprehensive care plans.
- Assists patients, families, and caregivers with identified problems, concerns and expectations and provides guidance as needed.
- Tracks and monitors patients requiring care coordination across continuum of care and services. Ensures accuracy and quality of tracking.
- Maintains and documents program activities. Creates and provides population-based reports on outcomes specific to at-risk and frail elderly patients.
- Documents all care provided to patients including provider orders, treatments, plans and instructions in accordance with professional standards.
- Identifies opportunities to improve care and services for geriatric population and particpates in strategic planning of program.
- Participates in problem solving and quality improvement monitoring to help develop, implement and evaluate department and program specific standards, processes/workflows, policies/procedures, educational tools for the geriatric patient.
- Serves as resource to staff. Ensures training for ongoing formal and informal staff development needs.
- Develops and implements plans/projects to improve operational efficiency and effectiveness. Monitors status and progress and reports to supervisor.
- May perform patient care to the extent necessary to maintain clinical expertise, competency and licensing necessary to fulfill job responsibilities and to direct the provision of care on the unit.
- Maintains current working knowledge of Federal, State and Medicare regulations, resources within Kaiser, and the care community.
- Participates in performance improvements. Implements Quality Improvements processes. Performs clinical records audits. Maintains educational records and provides evidence of competency.
- Provides direct patient care on an as needed basis. Provides services that are within scope of license and in compliance with all legal, regulatory, and policy requirements relevant to clinical role performed.
- Incorporates the KP Nursing Vision, Model and Values through out their Nursing Practice.
Qualifications:
Basic Qualifications:
- Two years direct patient care experience.
- Two years case management or care coordination experience.
- Bachelor's degree in nursing or equivalent related experience.
- Valid Hawaii State RN license (must meet education requirement(s) for Hawaii State licensure).
- Current BLS for Healthcare Provider CPR or CPR/AED for the Professional Rescuer certification.
- Demonstrated knowledge of and skill in oral communication, written communication, customer service, conflict resolution, influence, problem solving, quality management, and systems thinking.
Preferred Qualifications:
- One year geriatric experience.
- Master's degree in public health, clinical nursing, or related field.
- Certified Case Manager (CCM) by the Commission for Case Manager Certification (CCMC).
- Demonstrated knowledge of and skill in word processing, spreadsheet, and database PC applications.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.