Case Manager Liaison Nurse - 0.6 FTE - Spokane (Onsite: Sacred Heart)

About the job

Kaiser Permanente is hiring a part-time (0.6 FTE) RN case manager liaison nurse for inpatient discharge planning, based onsite at Sacred Heart in Spokane. On a periodic rotation, the nurse plans follow-up care and discharges for Kaiser Foundation Health Plan of Washington (KFHPW) patients admitted to a nearby network facility and carries a caseload at a KFHPW medical center, aiming for the best patient outcomes with appropriate use of resources.

What you'll do

• Confirm that patients referred to case management meet its criteria, and assess each one's physical, mental, financial and psychosocial status with comprehensive, standardized criteria to find current and potential needs
• Build a patient-centered case management plan from the assessments, with the patient's goals, objectives and outcomes and specific short- and long-term time frames, and evaluate whether designated caregivers can support the patient
• Work with medical providers and primary and specialty care teams on a collaborative plan of care that helps patients follow the medical plan, function better and self-manage, aiming for a seamless continuum of care
• Coordinate and carry out interventions using evidence-based guidelines, recommend added services to the primary care provider as the plan calls for, and track progress against the original goals, updating needed services
• Stay in regular contact with the patient, family and care team, advocate for the patient's care needs, document patient responses to interventions, and join care conferences for complex cases on a limited basis
• Collaborate with other health care professionals on the plan of care, variances and outcomes, and record interventions and contacts with patients or caregivers as KFHPW and Care Management policy requires
• Monitor patients' short- and long-term responses to interventions, analyze variance patterns, gather data on how care coordination affects quality outcomes, finances, patient satisfaction and systems improvement, and help measure the program's effectiveness
• Recommend alternative care settings suited to the patient's needs and appropriate resource use, and refer patients to hospice, home health care, long-term care and other services or facilities as needed
• Act as the liaison within the KFHPW care continuum and with outside contracted providers, facilities and resources, giving the organization feedback on contracted services and leadership input on utilization, cost, quality, service and care delivery
• Apply health plan requirements and the patient's benefits in care management decisions, help patients understand and follow their treatment plans, and support patient education through referrals to chronic illness classes, group visits and community resources

Schedule

• Part-time, 0.6 FTE
• Variable weekday schedule, Monday to Friday, 8 a.m. to 4:30 p.m.
• Every other weekend on a rotation, plus holidays rotated among the team
• A periodic rotation between the two work settings

Benefits

• A sign-on bonus for eligible external hires
• The position is eligible for benefits