Serves in an expanded nursing role to collaborate with members and the care team to provide a model of care targeting the highest risk members post hospital discharge, across all chronic care pathways. Integrates evidence-based clinical guidelines, protocols, and other metrics in the development of treatment and care plans that are patient centric, promoting quality and efficiency in the delivery of the targeted population. Promotes optimum clinical outcomes providing assessment and management of critical transitions and panel management of the patient.

• Demonstrates knowledge of all Kaiser Permanente quality, safety, and emergency policies and procedures.
• Demonstrates quality and effectiveness in work habits and clinical practice in every interaction with patients, colleagues, providers, and leadership, procedures, infection prevention, fall prevention, including consistent use of two patient identifiers. Reports safety hazards, accidents and incidents, and unsafe working conditions promptly.
• Monitors members status to initiate and perform nursing care through health promotion, supportive or restorative care, disease prevention, ailment, pain, injury, deformity, and physical or mental condition using specialized knowledge, judgment, and skill involving the application of biological, physical, social, and behavioral science principles.
• Identifies and assesses emergency situations and initiates appropriate interventions.
• Utilizes advanced physical assessment skills in evaluating health status through the collection and assessment of health data NRS 632.018; NRS 632.0169
• Coordinates care with various internal and external customers to facilitate high quality, timely, cost-effective care and service. Ensures appropriate utilization of hospital and emergency room services by providing care coordination to members that are discharged.
• Reviews ordered therapies and treatment plans and validates comprehension of understanding
• Consults and educates other staff, physicians, departments and members regarding resource management options that provide high quality while efficiently using available resources.
• Provides culturally relevant education and teaching for members discharged from the hospital setting and enrolled into care management panel and families as applicable.
• Actively seeks information to understand member/patient circumstances, problems, expectations, and needs. Builds rapport and cooperative relationship with members/patients.
• Collaborates with primary care teams to determine appropriate population management focus depending upon quality outcomes.
• Responds quickly to meet member/patient needs and resolves problems.
• Refers to medical or community agencies per KP guidelines those patients who need further treatment, evaluation, or assistance.
• Local travel required to facilities to communicate, develop trust, and obtain critical patient/member information to inform the development of a care plan for the member.
• Practices within the scope of professional nursing practice as defined by Nevada licensure, applying knowledge, skill, and sound clinical judgment consistent with recognized nursing standards and KP guidelines (NRS 632.018; NRS 632.0169)
• Leads health care team by influence and role modeling integrated effective nursing practice, service, innovation and providing outstanding support for physician practices.