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Case Manager RN - Gender Pathways ClinicLocation: Portland, OR Job Number: 916870 Date posted: 12/17/2020
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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 Permanente's 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.
- 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.
- Strengthen and improve 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.
- Act as a liaison between the patient and appropriate care delivery team.
- Minimum two (2) years of demonstrated experience and training working with transgender/non-binary patients and families
- Within the last eight (8) years a minimum five (5) years of nursing experience in acute care or ambulatory care/clinic/extended setting is required with two (2) of those five (5) years being spent in a case management/care coordination role.
- Graduate of accredited school of nursing.
License, Certification, Registration
- Current Oregon and Washington RN license required. License in state where assigned required upon hire/transfer, application for license in secondary state required within two (2) weeks of hire/transfer and must be obtained within six (6) months.
- Basic Life Support (BLS) for Health Care Providers required upon hire/transfer.
- Valid driver's license.
- Must have knowledge of adult case management practices
- Demonstrate and maintain knowledge of current gender affirming surgical practices
- Demonstrate and maintain knowledge and experience working with transgender, non-binary patients to navigate through the care continuum
- Appropriately apply evidence-based protocols
- Understanding of issues impacting transgender/non-binary patients and families
- Knowledge of community resources and services for the transgender/non-binary community
- Excellent written and verbal communication skills
- Knowledge of case management principles.
- Demonstrates clinical nursing and leadership skills.
- Ability to work independently in an unstructured environment with minimal supervision
- Able to type 20 words per minute.
- Demonstrates effective interpersonal, communication and problem-solving skills.
- Willingness to learn computerized information systems.
- Demonstrates ability to work within teams and within a dynamic work environment.
- Demonstrates customer-focused service skills.
- Knowledge of community resources for the care of the elderly, and patients with chronic conditions.
- Demonstrated ability to organize, coordinate, and manage care plans. Thorough knowledge of levels of care within outpatient, acute care, and extended care settings.
- Demonstrated ability to work as part of a multidisciplinary team.
- Effective written and verbal communication skills.
- Ability to present reports verbally in a public setting (public speaking).
- Demonstrated data entry skills and ability to use Microsoft Word software.
- Minimum two (2) years of experience in case management, care coordination, or population care.
- Experience with care/case management, triage & advice for surgical population (gender-affirming surgery).
- Experience and skill with telephonic patient assessment.
- Experience working from standardized policies and procedures.
- Previous experience with population care/case management, triage and advice.
- Microsoft Word, Excel, and Health Connect experience.
- Quality management methodology and utilization management experience.
- Current or future bachelor's degree in nursing or related field.
- Case Management Certification.
- BSN or MSN degree preferred
- Certification in Case Management; Certification in Nursing preferred.
- Knowledge in development and implementation of care coordination systems, processes and communication to support transgender services.
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.
Learn About Nursing & Physician Assistant Careers
Through professional practice and leadership, nurses at Kaiser Permanente continually advance the art and science of nursing. But we recognize that what we do is more than clinical practice. We believe that every interaction — whether it is with a patient, a colleague, a physician, or anyone else — has the potential to be extraordinary. And we find that approaching our daily routine with this in mind gives each and every action new meaning and allows us to focus on the moment, empowering us to deliver expert care.
No matter where you are in your nursing career, the size and scope of our organization means you have the resources, technology, tools, and support you need to make a lasting impact.
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Physician assistants play a powerful and important role in delivering high-quality, informative care. Working directly with patients, their families, colleagues, and supervising physicians, they are vital in defining the overall care experience.
Being a physician assistant at Kaiser Permanente is centered on promoting a healing environment — one that maintains a caring, comforting practice while honoring the unity of the whole patient: mind, body, and spirit.
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