Transitions of Care Liaison Nurse

**  Must Live Within Commutable Distance of Spokane WA  - Onsite Work Location Kaiser Riverfront Clinic in Spokane  ** 

Phone/Computer-Based Work  -  Monday-Friday/Alternating Weekends Sat/Sun – Holidays, Rotated Among Team 8\:30a-5\:30p

Position Involves (But Not Limited To)\: Calling members that have recently been discharged from the hospital setting to perform a medication review and assessment, as well as following the member for up to 30 days for check-ins as needed. Transitions of Care Liaison Nurse will assist with making sure the member has everything that they need to transition to home setting, assisting in reducing the need for hospital readmissions.

Job Summary\:

• 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 GH 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.

**  Must Live Within Commutable Distance of Spokane WA  - Onsite Work Location Kaiser Riverfront Clinic in Spokane  ** 

Phone/Computer-Based Work  -  Monday-Friday/Alternating Weekends Sat/Sun – Holidays, Rotated Among Team 8\:30a-5\:30p

Position Involves (But Not Limited To)\: Calling members that have recently been discharged from the hospital setting to perform a medication review and assessment, as well as following the member for up to 30 days for check-ins as needed. Transitions of Care Liaison Nurse will assist with making sure the member has everything that they need to transition to home setting, assisting in reducing the need for hospital readmissions.

Job Summary\:

• 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 GH 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.

• 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.

• Bachelors degree.

• 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
   

• 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.

• Minimum two (2) years of RN experience in utilization review, ambulatory case management, care coordination or disease management.
• Bachelors of science in Nursing

• 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.

• Bachelors degree.

• 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
   

• 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.

• Minimum two (2) years of RN experience in utilization review, ambulatory case management, care coordination or disease management.
• Bachelors of science in Nursing

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