Job Summary: Provides case management and outreach services to selected patients. Acts as medical liaison between patient, PCP, interdisciplinary team staff, and other KP providers. Coordinates and evaluates administrative and operational activities of services required to respond effectively to patients medical needs. Assesses individual patient/families to identify specific interventions that are clinically appropriate and within patients preferences. Provides continuity to patient/family by coordinating care and services needed in all settings in the healthcare continuum. Monitors plan of care and assesses patient progression while receiving services from interdisciplinary team providers. Provides ongoing communication to PCP, interdisciplinary team, and to other members of the patient care team. Serves as a leader for the interdisciplinary team for medically complex patients. Essential Responsibilities: Monitors high-risk members and assists them with access to care. Provides case management services to patients/families requiring complex care management by assessing and evaluating their needs and any potential care gaps. Devises individualized plans of care to ensure completion of treatment as recommended by physician and/or other health care providers. Develops work plans to assist patients/families in meeting identified medical, social, or other needs. Coordinates resources and integrates patients into existing programs/services to assure continuity and quality of care. Evaluates outcomes and makes recommendations for change. Monitors plan of care and assesses patient progression while receiving complex care coordination services. Provides ongoing communication to PCP, interdisciplinary team, specialty providers, and other members of the patients care team. Identifies appropriate referrals and resources, acts, and makes commitments to solve individual patient care management problems. Acts as clinical liaison between patient, community resources, and medical staff. Provides continuity of care to patients by coordinating care and services needed by patients and members who are at high risk of readmission to the emergency room and/or hospital. Participates in problem solving and quality improvement monitoring to help develop, implement, and evaluate department specific processes/policies. Assists and advises in development of standards, policies and procedures and educational tools for various patient treatments. Serves as resource to staff. Ensures training for ongoing formal and informal staff development needs. Develops and implements plans/projects to improve operational efficiency and effectiveness. Monitors status and progress and reports to supervisor. Expresses opinions and uses negotiation skills to influence financial outcomes related to hospital days, alternative care, and other referred services. Seeks clarification of incomplete or illegible records including inpatient and outpatient records and reports problems for corrective action. Identifies and reports potential risk cases or situations. Maintains confidentiality of patient records, information, and departmental activities involving patient information. Practices within ethical and legal guidelines using established policies and procedures. Displays an awareness of individual rights of patients and educates the member about those rights. Participates in departmental activities related to education, staff meetings, guidelines, and policy development. Demonstrates competency to adhere to organizational policies, procedures, and rules. May provide patient care on an as needed basis to the extent necessary to maintain clinical expertise, competency, and licensing necessary to fulfill job responsibilities and to direct the provision of care. Provides services that are within the scope of license and in compliance with all legal, regulatory, and policy requirements relevant to clinical role performed. Basic Qualifications: Experience Minimum two (2) years direct patient care experience as a licensed RN. Minimum two (2) years case management or care coordination experience. Minimum one (1) years hospice or palliative care experience. Education Bachelors degree in nursing or four (4) years of directly related experience. High School Diploma or General Education Development (GED) required. License, Certification, Registration Registered Nurse License (Hawaii) required at hire Basic Life Support from American Heart Association Additional Requirements: Knowledge of medical diagnosis, care pathways, nursing care, ambulatory care, utilization management, member benefits, and Medicare benefits. Successful completion of motivational interviewing course within 6 months of hire. Preferred Qualifications: Minimum one (1) year of recent experience in Palliative Care in hospital or outpatient setting. Completion of palliative care training including pain and symptom management, nutrition and hydration, psychosocial and spiritual care, and hospice. Case management or home health experience. Masters degree in public health, clinical nursing, or related field.