RN, Team Lead-Home Health (FT, Days)

To ensure coordination of care and services provided to all patients receiving home care services in the Home Health Program. Key functions include developing a coordinated admission plan of care, facilitating coordination of disciplines and services, using problem-solving and critical thinking skills to address clinical problems, and facilitating transitions across healthcare settings.

Responsibilities

• Receives and evaluates the appropriateness of home health referrals in collaboration with care team members, supervisors, schedulers, and physicians.
• Ensures timely admission based on assessment of clinical needs, patient/caregiver ability to manage self-care, and other safety factors.
• Coordinates appropriate services and interventions by obtaining initial physician orders (e.g., wound care, medications).
• Develops and coordinates a comprehensive admission plan of care, incorporating patient-specific benefits and eligibility requirements.
• Ensures availability of supplies and equipment (e.g., wound supplies, DME, enteral pumps, glucometers) to meet patient needs.
• Makes recommendations to modify the plan of care to enhance patient outcomes and reduce risks.
• Communicates start of service to patients, caregivers, and scheduling staff based on physician orders.
• Collaborates with referral sources, home care team members, and physicians regarding complex or unsafe discharge plans.
• Identifies and coordinates alternative care options, including on-site or telephone conferences with healthcare teams.
• Advocates for patients and families to optimize resource utilization and ensure financial obligations and appeal rights are understood.
• Coordinates referrals to contract and non-contract providers for services not available within the agency.
• Maintains expert knowledge of agency policies, state/federal regulations, and home care qualifications.
• Provides telephone advice, problem-solving, and follow-up for patients, caregivers, and home care staff.
• Facilitates scheduling of follow-up visits, procedures, and staffing to meet patient needs.
• Oversees supply and DME ordering, physician paneling, and care conferences.
• Conducts medication reconciliation and reviews/approves Home Health Aide Care Plans for therapy-only cases.
• Coordinates and tracks referrals and transitions across care settings (e.g., home phlebotomy, wound programs, inpatient transfers).
• Acts as a Kaiser Permanente ambassador to care facilities, addressing barriers to safe transfers and quality care.
• Provides education and program development, including staff orientation and mentoring.
• Ensures regulatory and compliance standards are met through collaboration with the interdisciplinary team.
• Participates in quality and utilization management activities (e.g., chart audits, continuing education).
• Conducts patient home visits as required and provides cross-coverage for Home Health programs.
• Participates in program call duty and other assigned duties.

Requirements

• Minimum two (2) years of home health experience as an RN.
• Minimum one (1) year of leadership experience or commensurate experience.
• Bachelor’s 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.
• Registered Nurse License (Washington) or Compact License (Registered Nurse License in Oregon).
• Valid Driver’s License (in location where applicable).
• Basic Life Support certification.

Skills

• Ability to collaborate with physicians, ancillary providers, nurses, and patients for care transitions.
• Triage and phone experience.
• Proficiency in complete physical and psychosocial assessments.
• Ability to operate clinical tools (e.g., stethoscope, sphygmomanometer).
• Keyboarding and computer skills for clinical documentation.
• Strong problem-solving, written, verbal, organizational, and time management skills.
• Knowledge of Medicare, The Joint Commission, and state regulations for home care.
• Knowledge of Kaiser Permanente systems.

Preferred Qualifications

• Minimum four (4) years of experience as an RN in acute care (medical/surgical or critical care) and at least one year in a Kaiser Permanente Home Care Program (Home Health, Home Infusion, Hospice, or Palliative Care).
• Experience with care coordination, case management, or discharge planning.
• Customer-focused service skills and familiarity with computer systems.
• Thorough knowledge of Medicare regulations for home care.
• OASIS-C Certification.
• Experience in oncology, rehabilitation nursing, or utilization management.

Schedule

• Full-time (40 hours per week).
• Shift: Day (working hours between 07:00 AM and 06:00 PM).
• Workdays: Monday through Sunday (variable schedule).
• Travel: 100% of the time (reliable automobile required).

Pay

$56.28 - $82.02 per hour. Kaiser Permanente offers a market-competitive total rewards package, with pay determined by labor market data, internal alignment, and candidate qualifications (e.g., experience, education, certifications, skills, and geographic location).