Case Manager Liaison Nurse - Outpatient Complex Care Coordination (Pediatrics) 1.0 FTE - Western WA

** CASE MANAGER LIAISON NURSE - OUTPATIENT COMPLEX CARE COORDINATION - PEDIATRICS! ** MUST LIVE IN WESTERN WA WITHIN COMMUTABLE DISTANCE TO A KPWA MEDICAL CENTER ** FLEXIBLE ROLE WORKING 4-10'S ~ (3) DAYS ONSITE KPWA MEDICAL CENTER AND (1) DAY REMOTE ~ MON - FRI 7:00AM - 5:30PM ** KPWA MEDICAL CENTER PRIMARY WORK SITE WILL BE BASED ON GEOGRAPHICAL LOCATION OF FINALIST SELECTED PEDIATRICS EXPERIENCE HIGHLY PREFERRED The Complex Case Manager in this position will work in a designated clinic setting 3 days per week and will telecommute remaining days in the work week. Primary responsibility is to provide and coordinate nursing care for the member in collaboration with the Health Care team = Pediatrics in this case,, including medication management of specific chronic conditions, focus on achievement of optimal patient health care outcomes while ensuring appropriate utilization of health care resources. Will be working closely with Pediatric/Family Care teams and specialty care teams and medical providers - the liaison nurse will establish a collaborative plan of care to assure adherence to the medical plan, improvement in functional status and improved ability to self-manage. Participate in medication management through well-established protocols within internal delivery systems.

The Care Manager will work in two settings on a periodic rotating schedule, planning the discharges and follow up care for Kaiser Foundation Health Plan of Washington patients hospitalized at a nearby network facility and carrying a case load of patients in one of the Kaiser Foundation Health Plan of Washington medical centers. Some weekends and holidays are required, and scheduled days of the week are variable. Primary responsibility is to focus on achievement of optimal patient health care outcomes while ensuring appropriate utilization of health care resources. Working closely with primary care teams, specialty care teams and medical providers, the Liaison Nurse will establish a collaborative plan of care to assure adherence to the medical plan, improvement in functional status, and improved ability to self-manage. Serves as the liaison across the internal KFHPW care continuum and between KFHPW and all externally contracted providers, facilities, and resources and provides feedback to the organization regarding the service and quality of contracted services. The Liaison Nurse collects data and provides input to leadership regarding issues or concerns related to utilization, cost, quality, service and care delivery to patients.

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.