Description: Job Summary:
Plans, develops, assesses, and evaluates care provided to patients.  Provides case management and outreach services to selected patients. Assists with discharge planning and follow-up for hospitalized members.  Assists in the development of population care program.

Essential Responsibilities:

Provides case management services to targeted patients/families by interviewing and evaluating their needs. Develops work plans to assist patients/families in meeting identified needs. Coordinates resources and services to assure continuity and quality of care. Maintains working knowledge of community resources. Assist with interpreting Kaiser Permanente benefits/services to patients, families, and members of community. Monitors high-risk members and assists them with access to care. Integrates patients into existing programs/services. Evaluates outcomes and makes recommendations for change.
Assists with integrating programs and initiatives into daily practice. Makes clinic/location-specific adaptations as necessary to insure successful implementation of model. Monitors and evaluates outcomes. Assists and advises in development of standards, guidelines, policies and procedures. Coordinate and standardize patient education tools. Applies professional nursing care principles in the evaluation and treatment of patients.
Coordinates population based care. Serves as a link between members and all other care providers in coordination of care. Assists members, families and care givers with identified problems/concerns.  Arranges and monitors follow-up appointments and care. Encourages patients to maintain prescribed course of care, including but not limited to monitoring of side effects of medications. Makes referrals to appropriate community services. Communicates effectively with a variety of individuals in a non-judgmental manner, functioning calmly in situations which require a high degree of sensitivity, tact and diplomacy.
Completes all required patient care documentation accurately and in a timely manner in accordance with internal and external regulatory requirements.
Works with analytic staff and others to collect data, tracks outcomes, identifies barriers/gaps in care and support strategic planning processes. Maintains data bases to improve quality outcomes.
Attends scheduled patient care conferences, in-services, departmental meetings and all other related activities as requested.
May perform patient care to the extent necessary to maintain clinical expertise, competency, and licensing necessary to fulfill job responsibilities and to direct the provision of care on the unit.
Provides direct patient care on an as needed basis. Provides services that are within scope of license and in compliance with all legal, regulatory, and policy requirements relevant to clinical role performed.
Incorporates the KP Nursing Vision, Model and Values throughout their Nursing Practice. Basic Qualifications: Experience

Minimum (2) years of direct patient care experience.
Education
Bachelors degree in nursing; or four (4) years of directly related experience. License, Certification, Registration Registered Nurse License (Hawaii) required at hire
Basic Life Support from American Heart Association
Additional Requirements:
Case management/community outreach experience.Demonstrated knowledge of and skill in word processing, spreadsheet and database PC applications. Preferred Qualifications:
Program development and operations level implementation.