RN Nurse, Team Lead-Home Health (FT, Days)
Portland, OregonAt Kaiser Permanente our nurses are leaders, clinicians, researchers, innovators, and scientists who are contributing toward being an industry-leading voice for advancing evidence-based care. Whether supporting the patient directly in our hospitals or clinics, providing care at home, serving our patients through innovative virtual technology, or managing care delivery teams, Kaiser Permanente nurses utilize scientific evidence and our integrated care model to optimize the total health of our members and the communities we serve. We invite nurses who are passionate about nursing excellence, high-quality compassionate care delivery, professionalism, integrity, teamwork and patient and family centeredness to join our teams so that we can continue to sustain and build upon our culture of excellence.
- Job Type: Full-time
- Job Level: Individual Contributor
- Travel: Yes, 100 % of the Time
Success Profile
We’re looking for Nurse Leaders who possess the following traits.
- Collaborative
- Compassionate
- Flexible
- Leadership
- Socially Conscientious
- Trustworthy
Benefits
We offer several benefits to our nurses.
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Medical, Vision & Dental
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Retirement Plans
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Educational Opportunities & Tuition Reimbursement
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Supportive Teams & Resources
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Career Growth & Development
Our Culture
At Kaiser Permanente, we cultivate an environment of compassion, integrity, trust, and open communication that helps our teams do their best work. We believe that lifelong learning will expand our knowledge so we can better serve our patients. Our practice is rooted in research and evidence-based care. Our nurses reflect the rich diversity of our members and communities and provide culturally responsive and competent care that promotes understanding of our members needs and preferences. At Kaiser Permanente, nurses are highly skilled professionals who exemplify leadership, critical thinking, and collaborative problem solving and deliver the right care, at the right time, in the right setting.
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Kristen
Relief Charge Nurse
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Registered Nurse IV
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Inpatient Lactation Consultant
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Kimberly
Quality Coordinator RN
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David
Appointment and Advice RN
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Shawn
BSN, RN
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RN Nurse, Team Lead-Home Health (FT, Days)
Primary Location Portland, Oregon
Worker Location Flexible
Job Number 1323475 Date posted 12/02/2024
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Description:
To ensure coordination of care and services provided to all patients receiving home care services in the Home Health Program. Key functions are to develop a coordinated admission plan of care for patients referred; facilitate coordination of disciplines and services; use problem-solving and critical thinking skills to facilitate, coordinate, and execute effective, timely responses to clinical problems as they arise for patients and home care clinicians; and facilitate transitions across the continuum of healthcare settings for all home care patients.
Job Summary:
To ensure coordination of care and services provided to all patients receiving home care services in the Home Health Program. Key functions are to develop a coordinated admission plan of care for patients referred; facilitate coordination of disciplines and services; use problem-solving and critical thinking skills to facilitate, coordinate, and execute effective, timely responses to clinical problems as they arise for patients and home care clinicians; and facilitate transitions across the continuum of healthcare settings for all home care patients.
Essential Responsibilities:
- Referral and Admissions to Home Care: Receives and evaluates appropriateness of the home health referral in collaboration with other team members (care team members, supervisor, scheduler, care (discharge) coordinators, long-term care team, expanded care, physicians, clinic social workers, and others as needed). Ensures timely admission based on assessment. Assess clinical implications of services ordered, patient/caregiver ability to manage self-care, requirements for clinical monitoring, patient stability, patient behavior that could impact a safe plan of care, and other factors that could impact safety and efficacy of admission care plan. Coordinate appropriate services and interventions by obtaining appropriate initial physician orders (e.g. wound care; wound VAC, medications, etc). Participate in the development and coordination of a comprehensive admission plan of care that incorporates an understanding of patient-specific benefits and eligibility requirements in collaboration with care team, outpatient resources, and referring physician. Assure that appropriate supplies and equipment needed to provide initial services are available (e.g. wound supplies, wound VAC, DME, enteral pumps, glucometers, medications, etc) to meet patient needs. Make recommendations to modify the plan of care to expedite a safe transition of care, reduce risks, and enhance patient outcomes. Identify and communicate start of service to patient/caregiver and home care scheduling staff based on physician orders and patient care needs. Discusses and collaborates with referral source, home care team members, physician, discharge coordinator, and supervisor regarding complex discharges, unsafe discharge plans, and inappropriate referrals. Assists in identifying and coordinating alternative options to current care needs, which may include on-site or telephone conference with healthcare team members and patient/family/caregivers. Advocate for the patient and family, as well as the healthcare system to optimize utilization of resources. This includes acting on behalf of the member to ensure they are informed of their financial obligations and understand their appeal rights. Coordinates referrals out to contract and non-contract providers for members that require home care services that can not be provided by agency staff within the Portland/Vancouver service area. Develop and maintain expert level of knowledge and skills related to agency policy, state practice acts, applicable state and federal regulations, utilization management, and qualifications for home care services.
- Optimizes the patients home care plan by providing: Telephone Advice/Problem-solving for patients/caregivers. Follow up to after hours advice calls. Resource, support, and advice for home care staff. Physician communication and support. Facilitates scheduling of follow up visits and procedures related to advice calls. Oversees the day to day staffing and patient schedules and problem-solves staffing challenges to meet patient needs, within staffing rules. Supply and DME ordering. Assistance with paneling patients with physicians. Facilitates Care Conferences (Case Conferences, Complex Discharges, etc). Coordinates care with Home Phlebotomy. Conducts Medication Reconciliation for Therapy only cases. Reviews and approves Home Health Aide Care Plans for Therapy only cases.
- Coordinate, expedite, and track referrals and transitions across care settings (e.g. home phlebotomy referrals, wound program referrals, transfers to inpatient, transfers to ICF/SNF, and across home care programs). Acts as Kaiser Permanente ambassador to provide member information to care facilities (SNF/ICF, assisted living, adult foster care home, and residential care facilities) and problem-solve/facilitate any issues which present barriers to safe transfers and the provision of quality care (e.g. Special equipment needs, symptom/behavior management, financial assessment and plan, clinical instability, and complex care needs.
- Provide education and program development functions: Ensures systematic and on-going contact with hospital staff and other Kaiser Permanente Departments (e.g. GLTC, DME, Hospital Care Coordinators, Clinic Social Workers, Clinic case Managers, Pharmacy, Home Infusion Program, Membership Services, etc) to share information and ensure safe transitions of care. Provides education to staff to expedite safe transitions of patients across care settings. Participates in orientation of staff to the department. Ensure appropriate and timely care to patients through collaboration with inpatient staff, CCS home care staff, and outside resource staff. Provides mentoring and coaching, and input into staff evaluations and documentation of performance problems to Clinical Supervisor. Participates in professional committees and task forces as needed/requested. Ensure regulatory and compliance standards are met in collaboration with others in the inter-disciplinary health care team. Participates in quality and utilization management activities (e.g. Chart audits). Participates in continuing education to incorporate and maintain up to date knowledge and best practices in home health.
- Conducts patient home visits as required to assist the program in meeting patient needs.
- Cross Home Health program coverage as needed. Participate in program call duty as needed. Other duties as assigned.
Basic Qualifications:
Experience
- Minimum two (2) years home health experience as an RN.
- Minimum one (1) year leadership experience or commensurate experience.
Education
- Bachelors degree in Nursing (BSN) or four (4) years of recent experience in a directly related field.
- High School Diploma or General Education Development (GED) required.
License, Certification, Registration
- Registered Nurse License (Washington) OR Compact License: Registered Nurse
- Registered Nurse License (Oregon)
- Drivers License (in location where applicable)
- Basic Life Support
Additional Requirements:
- Demonstrated ability to collaborate with physicians, ancillary providers, nurses, and patients to plan for transition of care to and from the home setting.
- Triage/phone experience.
- Able to perform complete physical and psychosocial assessments.
- Able to operate stethoscope and sphygmomanometer.
- Keyboarding or typing skills.
- Able to operate a computer to perform clinical documentation.
- Highly effective problem-solving, written and verbal communication, organizational, and time management skills.
- Knowledge of Medicare, The Joint Commission, and State requirements and regulations for home care programs.
- Knowledge of Kaiser Permanente systems.
- Note: This position requires completion of a typing test.
- Note: This position requires a reliable automobile to travel to and from patient homes.
Preferred Qualifications:
- Minimum four (4) years experience as a registered nurse in the acute care preferably medical/surgical and/or critical care nursing and at least one year working in a Kaiser Permanente Home Care Program (Home Health, Home Infusion, Hospice, or Palliative Care).
- Experience with care coordination or case management.
- 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.
- OASIS-C Certification.
- Oncology.
- Rehabilitation Nursing.
- Utilization management, discharge planning, care coordination, and case management.
Notes:
- Variable shifts/days/weekends/holidays
Primary Location: Oregon,Portland,Kaiser Permanente Building
Scheduled Weekly Hours: 40
Shift: Day
Workdays: Mon, Tue, Wed, Thu, Fri
Working Hours Start: 08:00 AM
Working Hours End: 04:30 PM
Job Schedule: Full-time
Job Type: Standard
Worker Location: Flexible
Employee Status: Regular
Employee Group/Union Affiliation: W01|AFT|Local 5017
Job Level: Individual Contributor
Department: Mt. Scott Medical Offices - Home Health - 1008
Pay Range: $50.19 - $69.62 / hour
The ranges posted above reflect the location in the job posting. The salary range may vary if you reside in a different location or state than the location posted.
Travel: Yes, 100 % of the Time
Flexible: Work location is on-site at a KP location, with the flexibility to work from home.
Worker location must align with Kaiser Permanente's Authorized States policy.
At Kaiser Permanente, equity, inclusion and diversity are inextricably linked to our mission, and we aim to make it a part of everything we do. We know that having a diverse and inclusive workforce makes Kaiser Permanente a better place to receive health care, a more supportive partner in our communities we serve, and a more fulfilling place to work. Working at Kaiser Permanente means that you agree to and abide by our commitment to equity and our expectation that we all work together to create an inclusive work environment focused on a sense of belonging and wellbeing.
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. Submit Interest
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. Submit Interest
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