Job Summary: Provides case management and outreach services to selected patients. Provides discharge planning services and assists with follow-up for Health Plan members hospitalized at community hospitals. Incorporates Risk Management, Quality Management and Utilization Management concepts into daily hospital and clinic activities. Essential Responsibilities: • Implements Continuing Care programs and initiatives with Continuing Care providers and PCP Team. 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. • 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. Interprets 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 patients/families with identified problems/concerns. • Meets with Continuing Care providers and PCP Team to monitor targeted patients. Assists Team by coordinating community care. Explores options to assure that quality, cost-efficient care is provided. • Makes daily hospital rounds for early identification of UM and discharge planning activities. Assists physician/patient/family in planning discharge. to facilitate smooth transfer to home or alternate facility. • Reports any Risk/Quality/Utilization Management issues to Neighbor Island Management Team. • Acts as contact person for MOA/Oahu discharges. Assists patients with smooth transfer to home. • Participates in community hospital interdisciplinary team meetings. • Maintains confidentiality of all patient information. • 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. • Develops and maintains collegial and consultative working relationship with Government Programs office staff to assure that all regulatory requirements are met and necessary changes are implemented. • Attends community seminars and workshops specific to professional needs. Participates in approved educational programs. • Assists in developing, implementing, maintaining, evaluating, and enhancing Total Quality Management activities within organization. Makes suggestions for change/improvement as indicated. • Incorporates the KP Nursing Vision, Model and Values through out their Nursing Practice.