Description: Job Summary: To ensure coordination of care and services provided to all patients receiving services in the Home Infusion 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 facilitate transitions across the continuum of healthcare settings for all patients in the Home Infusion Program. The Home Infusion Team Leader, under the direction and in partnership with the Home Infusion Manager and Home Infusion Supervisor provides clinical leadership for the home infusion team to enhance the delivery of timely high quality and cost-effective care which meets all regulatory, accreditation, licensure and certification requirements. Essential Responsibilities: Referral and Admissions to Home Infusion:Receives and evaluates appropriateness of the home infusion referral in collaboration with other team members (care team members, pharmacists, pharmacy technicians, supervisor, scheduler, 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, vascular access, 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. vascular access, 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, referring physician and when appropriate, the infusion program medical director.Assure that appropriate supplies and equipment needed to provide initial services are available (e.g. IV supplies, 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.Conferences with interdisciplinary home infusion team to identify and communicate start of service to patient/caregiver based on physician orders and patient care needs. Discusses and collaborates with referral source, home care team members, physician, discharge coordinator, supervisor and in some cases the infusion program medical director 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 cannot 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.The Home Infusion Team Leader will assist in the supervision of home infusion nursing personnel by: Oversite of day-to-day staffing and patient schedules.Assists with monitoring of staff performance, provides input into staff evaluations and documentation of performance problems to Home Infusion Supervisor and Home Infusion Manager. Leads daily Am board meeting with Home Infusion Pharmacy staff.Assists with interviewing process of applicants and provide hiring recommendations to Home Infusion Supervisor and Home Infusion Manager.Leads case conference/team meetings.Optimizes the patients home care plan by providing:Telephone Advice/Problem-solving for patients/caregivers.Follow up to afterhours 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, IDT, 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, respites, 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. LTC, Expanded Care, DME, Hospital Care Coordinators, Clinic Social Workers, Clinic Case Managers, Pharmacy, Home Health and Hospice 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.Makes home visits with Home Infusion Nurses to assure employees providing home infusion care have knowledge and skills required to provide age-appropriate care to patients and families through education, training or experience. 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 infusion and home health.Provides expert practice consultation for the home infusion team, CCS outpatient and skilled nursing facility staff.Assures professional competency through maintaining state of the art skills and knowledge consistent with Medicare and JCAHO regulations, applicable nurse practice acts and agency policies.Conducts patient home visits as required to assist the program in meeting patient needs.Participate in program call duty as needed. Performs other duties as assigned. Basic Qualifications:ExperienceMinimum two (2) year of medical-surgical nursing experience in an acute care setting.Minimum two (2) years of experience within the past five (5) years as a home infusion nurse or home infusion referral nurse.Minimum one (1) year of leadership experience or commensurate experience.EducationBaccalaureate degree in nursing or commensurate knowledge and experience.License, Certification, RegistrationThis job requires credentials from multiple states. Credentials from the primary work state are required at hire. Additional Credentials from the secondary work state(s) are required post hire.Registered Nurse License (Washington) within 6 months of hire OR Compact License: Registered Nurse within 6 months of hireRegistered Nurse License (Oregon) within 6 months of hireDrivers License (in location where applicable)Basic Life SupportAdditional 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, psychosocial, spiritual 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 of experience as a registered nurse in the acute care preferably medical/surgical and/or critical care nursing and at least one (1) year working in a Kaiser Permanente Home Care Program (Home Infusion, Home Health, Hospice, or Palliative Care).Experience with care coordination or case management.CRNI certification.OASIS-C CertificationHome health nursing.Pediatric and well child nursing.Oncology and hospice nursing.IV therapy nursing.Rehabilitation nursing.Pediatrics, including well childcare.Oncology/hospice.Rehabilitation nursing.Hospice care and the dying process.Utilization management, discharge planning, care coordination, and case management.Demonstrated customer-focused service skills.Familiarity with the use of computers and competence in keyboarding skills.Medicare regulations.Peripheral and central line IV management.Notes:Variable shifts/days/weekends/holidays