Job Summary:
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 Permanentes 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 Responsibilities:
• Utilize regional population stratification information and processes to identify appropriate members for enrollment into case management in collaboration with clinicians and health care team. • 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; and reinforces the treatment plan. • Advising and coaching patients and families; Succinctly document interventions in KP HealthConnect as needed by other providers to ensure coordination of care and services.
Strengthening and Improving Case Management Services:
• Establish strong relationships with clinicians and other health care team members. • Communicate data on population case managed, utilization and outcomes. • Education of staff/clinicians. • Development and distribution of education, tools and materials for member coordination. • Contributing to ongoing process improvement including related procedures, policies, patient support and documentation tools.
Acting as a Liaison between the Patient and Care Delivery Team:
• Act as a liaison between the patient and appropriate care delivery team.