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RN, Home Health Access

Primary Location Portland, Oregon Job Number 1080483 Date posted 06/30/2022
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The Home Health Access RN provides quality, cost effective clinical coordination & transitions to the home from the acute care, emergency care settings, & clinic or primary care. The Home Health Access RN manages patients w/ routine & complex discharge planning needs through collaboration w/ inpatient &/or SNF care coordination. The Home Health Access RN also serve as expert resource consultants & educators for physicians & other health care team members in transitions of care to the Home Health Program, coordination of internal & community resources, & support the evaluation & improvement of systems of care to support the optimal utilization of home health resources, while maintaining quality of patient care.

Essential Functions:
- Quality & Srv:Providing an exceptional patient care experience, consults w/ patients, families, physicians & hospital staff to gather appropriate clinical & demographic data to ensure a smooth transition from hospital to home health care. Provides an exceptional patient care experience that includes appropriate patient care planning according to the needs of the patient & family/caregiver members. Collaborates w/ insurance companies, other managed care entities, DME providers & others to provide assistance to field staff in the Case Management process to provide an exceptional patient care experience. Promotes & maintains continuity of care for patients being discharged from the hospital, clinic or SNF to home care srvs.
- Communication & coordination:Triages incoming referrals based on the patient needs. Determines initial level of care & srvs ordered & assesses the need for additional srvs for patients referred to Home Health. Provides oversight & supervision for LPN & Referral Coordinators to support timely admission to the home health program. Utilize case/family conferences & consults to develop these care plans as needed. Implementing care plans by ordering, brokering, & advocating for the patient & family, while educating the patient, family, & health care team about options & alternatives. Notifies CCS Mrgs of any discharges of patients w/ complicated social & medical issues that delay initiation of home care.
- Education, documentation & program development functions:Educates patients, their families & the facility staff about the srvs & products provided by Kaiser Continuing Care Srvs. Make recommendations to modify the plan of care to expedite a safe transition of care, reduce risks, & enhance patient outcomes. Accurate documentation of all patient/caregiver contact & communication w/ clinic staff, PCPs, hospital care coordination in both the agency record &/or in Healthconnect to assure CCS staff are informed of all interventions undertaken in patients' behalf. Ensures systematic & on-going contact w/ hospital staff & other KP Depts (e.g. GLTC, DME, Hospital Care Coordinators, Clinic Social Workers, Clinic case Mrgs, Pharmacy, Home Infusion Program, Membership Srvs, etc) to share information & ensure safe transitions of care. Participates in quality & utilization management activities (e.g. Chart audits). Participates in continuing education to incorporate & maintain up to date knowledge & best practices in customer srv & exceptional clinical care for the home setting. Completes Medication Reconciliation for therapy only cases per regulations & standards. Assists RN team w/ optimizing the patient's home care plan by providing: Resource, support,
& advice for home care staff Physician communication & support. Supply & DME ordering as needed. Assistance w/ paneling patients w/ physicians.
- Regulatory:Ensure regulatory & compliance standards are met for admission to home care programs. Understands Medicare guidelines & is responsible for adherence to all state & federal regulations & JCAHO standards.
- Productivity: Supports productivity for field staff & participates in productivity work w/in the CCS Dept.
- Covers patient advice calls as needed. Participate in program call duty as needed. Conducts patient home visits as required to assist the program in meeting patient needs. Perform other duties as requested.
- Management identifies these positions as highly skilled RN's who may provide coverage (may not always require travel to facility) for any of the below positions for vacancies w/ vacations or ill calls. KSMC - identifies patients discharging to the Home Health Program & make contact to assure a smooth, seemless transition that meets the patient needs. WSMC - identifies patients discharging to the Home Health Program & make contact to assure a smooth, seemless transition that meets the patient needs. SNF/clinc - identifies patients discharging to the Home Health Program & make contact to assure a smooth, seemless transition that meets the patient needs. Office - Referral triage, manage clinical aspects of referral, patient outreach to improve patient outcomes.

Basic Qualifications:
- Minimum two (2) years of experience as a registered nurse in the acute care setting preferably medical/surgical and/or critical care nursing OR Minimum one (1) year home health or home infusion experience in the past 10 years.
- BSN OR one (1) year recent experience in Community Health, Home Health, Hospice, or Palliative Care.
- High School Diploma or General Education Development (GED) required.
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 2 weeks of hire/transfer and must be obtained within 6 months.
- Drivers Licenses required upon hire/transfer.
- Basic Life Support (BLS) for Health Care Providers required within 2 weeks of hire/transfer.
Additional Requirements:
- Provides an exceptional patient care experience and exceptional customer service experience as evidenced in performance appraisal, patient compliments and references, and/or customers.
- Triage/phone experience with exceptional customer service experience as evidenced by past patient compliments and performance appraisals.
- Highly effective problem solving, written and verbal communication skills that lay the foundation for building relationships within the continuum of care.
- Able to operate a computer to perform clinical documentation.
- Highly effective organizational and time management skills that meet patient and organization needs.
- Knowledge of Medicare, The Joint Commission, and State requirements and regulations for home care programs as evidenced by demonstration prior to hire.
- Knowledge of Kaiser Permanente systems.

Preferred Qualifications:
- Minimum two (2) years experience as a registered nurse in the acute care preferably medical/surgical and/or critical care nursing and at least two years working in a Home Care Program (Home Health, Home Infusion, Hospice, or Palliative Care).
- Experience with care coordination or case management.

- OASIS-C Certification.

- Ability to write reports and procedures and document in the medical record.
- Ability to communicate effectively with, managers, patients, physicians, family members and the general public. Must be able to read, write, and speak English. Must be computer literate.
- Demonstrated customer-focused service skills.
- Familiarity with the use of computers and competence in keyboarding skills.
- Thorough working knowledge of Medicare regulations for home care.
- Oncology
- Rehabilitation Nursing
- Utilization management, discharge planning, care coordination, and case management.

Primary Location: Oregon,Portland,Kaiser Permanente Building Scheduled Weekly Hours: 1 Shift: Day Workdays: Variable Working Hours Start: 07:00 AM Working Hours End: 06:30 PM Job Schedule: Call-in/On-Call Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: W01|AFT|Local 5017 Job Level: Individual Contributor Department: Montgomery Park - Home Health - 1008 Travel: No Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.