The Care Manager will work in 2 settings on a periodic rotating schedule, planning the discharges and follow up care for Kaiser Foundation Health Plan of Washington patients hospitalized at a nearby network facility and carrying a case load of patients in one of the Kaiser Foundation Health Plan of Washington medical centers. Some weekends and holidays are required, and scheduled days of the week are variable. Primary responsibility is to focus on achievement of optimal patient health care outcomes while ensuring appropriate utilization of health care resources. Working closely with primary care teams, specialty care teams and medical providers, the Liaison Nurse will establish a collaborative plan of care to assure adherence to the medical plan, improvement in functional status, and improved ability to self manage. Serves as the liaison across the internal KFHPW care continuum and between KFHPW and all externally contracted providers, facilities, and resources and provides feedback to the organization regarding the service and quality of contracted services. The Liaison Nurse collects data and provides input to leadership regarding issues or concerns related to utilization, cost, quality, service and care delivery to patients.

• Ensures patients referred to case management meet established case management criteria. Assess all patients referred for case management to determine physical, mental, financial, psychosocial status, utilizing comprehensive, standardized criteria to identify existing and potential needs. Develop patient centered case management plan based on assessments and including patient goals, objectives, and outcomes with specific time frames (long/short term). Evaluate ability and availability of designated caregiver(s) to provide patient support. Coordinate and implement interventions using evidence based guidelines. Recommend additional services to PCP as determined in the case management plan. Conduct ongoing assessment of progress against original goals. Continuously update needed services. Maintain ongoing communication with patient/family and care team. Acts as an advocate for patient care needs. Documents all responses of patient to case management interventions.
• Collaborates with other health care professionals regarding the plan of care, variances in plan implementation, achieved outcomes or expected outcomes. Monitor and evaluate short and long term patient responses to therapeutic interventions and analyze patterns of variance from clinical information and outcomes. Recommend alternative settings for care based on health care needs and appropriate utilization of health care resources. Document interventions and interactions with patients or caregivers according to GH and Care Management policy and procedure. Participate in the measurement of the effectiveness of the case management program.
• Directs and guides the plan of care to result in a seamless continuum of care. Facilitates as needed, referrals for home health care, long term care, hospice, and other care facilities or services. Participation in care conferences to provide problem solving for patients with complex care needs (limited basis). Collects needed data needed to evaluate the effects of care coordination on quality outcomes, fiscal parameters, patient satisfaction and systems improvement. Understands and utilizes health plan requirements and patient benefits in making care management decisions. Assists patient to understand and comply with their medical treatment plan. Supports patient education and activation through referral to specific chronic illness classes, group visits or community resources.