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Registered Nurse (RN)

Company: MultiCare
Location: Auburn
Posted on: January 17, 2020

Job Description:

The RN Personal Health Partner (PHP) is responsible for exemplary cross continuum care coordination. This individual works with physicians, peers, community colleagues, and others to orchestrate care across the health care continuum, to identify opportunities to continually improve patient care and services, to improve population health, and to achieve collaborative practices that exemplify MultiCare Health System's commitment to patient centered care and community engagement.


BSN or Associates Degree in Nursing with other Bachelor's degree

3 years of recent clinical hospital/ambulatory experience

RN, licensed in the State of Washington

Healthcare financial and reimbursement knowledge preferred

Leadership and emergency services experience a plus



- Ensures that the division's mission, vision, and values are actualized

- Provides exemplary customer service to the patient, family, physician, and care team members

- Models and orchestrates consistent, professional communications and maintains consistent and proactive communication patterns with colleagues and staff

- Establishes rapport and relationships with hospital staff and leaders, community physicians, physician practices, and post acute providers

- Highly visible within MultiCare Health System (MHS) facilities and the "market"

- Responds positively to change

- Delegates responsibilities appropriately, but remains accountable for outcomes

Patient and Family

- Ensures that the patient and family experiences seamless and safe transitions of care

- Ensures that patient and family engagement are an integral and essential component of the care delivery process

- Advocates for patients and families

- Ensures face-to-face communication with the patient and/or family within 24 hours of admission to the hospital, to introduce the role of the PHP and to initiate the transition of care plan, or as soon as medically appropriate in other sites of care, such as the emergency department, outpatient bed, urgent care or community care facility

- Engages the patient, family, and physician and staff, in development of a post acute plan of care, and/or, a health maintenance and health promotion plan of care

- Visits each patient daily, while in the hospital

- Provides pertinent patient and family education consistent with MHS Transitions of Care standards

- Develops patient self management goals and monitors the progress of the goals

- Ensures that patients and families receive education on health and wellness activities, disease process and interventions, next steps, and other critical factors in overall health maintenance and improvement


- Partners with and supports physicians in patient care activities and care transitions

- Supports physicians in navigating the complex challenges of compliance and cost effective care

- Serves as a resource for physicians on health industry trends, rules, regulations, reimbursement, denial management and avoidable days, clinical cost reduction, etc.

- Collaborates with physician(s) to set daily rounding times or meetings based on the physician schedule and what is best for the patient

Participates in, and contributes to, daily physician rounding

- Engages physician partners in care improvement and resource management activities


- Develops significant market savvy, ensuring that services and interventions address the needs of the market demographic, and are sensitive to cultural and ethnic practices and beliefs

- Establishes significant functional relationships with community providers and community service agencies, ensuring that the integrity of care and service is monitored at those sites

- Understands community health challenges and works with director and division staff and colleagues to develop and implement practices, education programs, and other strategies to improve the health of the community and to promote continuous improvement in health status across the continuum

- Visits community care providers to develop rapport, understand service offerings, and insure quality and consistency of services

- Diligently supports and participates in division and market specific strategies

- Works with post acute care staff to develop community strategies for post acute and community services

Care Facilitation and Coordination

- Accountable for transitions of care and care across the continuum

- Orchestrates care between multiple care delivery sites and multiple caregivers

- Performs cross continuum care activities, which may include clinic, physician practice, urgent care, patient home, skilled care, remote monitoring or other sites of care

- Synchronizes care with all providers and colleagues

- Mobilizes resources to move patients through the hospital stay and across the continuum of care efficiently and effectively

- Adheres to MHS Transitions of Care standards

- Interacts with consulting physicians and other healthcare providers to facilitate throughput

- Collaborates closely with social work colleagues on all aspects of care delivery

- Works quickly to address barriers and challenges associated with cross continuum care coordination and engages colleagues and staff in hard wiring appropriate solutions

- Accountable for accurate and timely documentation

- Monitors documentation in the medical record daily, to ensure that care is accurately reflected

- Assists and collaborates in the management of patients with chronic diseases following established protocols and interventions

- Ensures absolute compliance with CMS and other regulatory initiatives

- Manages and includes in the plan of care, contributing factors such as obesity, age, diabetes, medications, etc.

- Coordinates healthcare interventions for populations with significant health conditions in which self-management efforts are critical

- Proactively manages payer communications and issues

- Assesses the need for, sets up and monitors remote monitoring equipment for patients.

- Ensures that appropriate handling of any issues generated through remote monitoring program.


- Participates in pertinent, ongoing, relevant education that contributes to professional knowledge and enhances practical abilities. Attends 70% of division educational programs.

- Attains significant knowledge of Population Based Care, Clinical Integration and Accountable Care

- Provides at least two educational programs per year to hospital staff

- Participates in and supports research activities

- Develops expertise on Centers for Medicare and Medicaid (CMS) rules, regulations, payment changes and trends, demonstration projects, and required data submissions

- Stays abreast of CMS core measures and National Patient Safety Goals (NPSGs)

- Stays abreast of industry trends and regulations and serves as resource for staff, colleagues, and physicians

- Maintains proficiency in reimbursement and denials management including physician and hospital, inpatient and outpatient payment structures, payer contracts, and health industry changes

- Adequate knowledge of normal ranges of vital signs as it pertains to chronic illnesses.

Assessment & Analysis

- Accesses and acts on information related to readmissions, throughput activities, denials, and barriers to effective care

- Stays alert for, and acts upon opportunities for, improvement of care and processes

- Maintains constant awareness of performance and service outcomes, inclusive of financial, operational, process, value, and relational coordination measures

- Understands and analyzes data related to patient populations/conditions and develops a plan of action. Monitors progress over time and initiates changes as needed

- Immediately addresses deficits as they are identified, including those that arise through remote monitoring.

- Engages physicians, hospital staff and leaders, and community partners in analysis, intervention and resolution activities for all departmental programs.

- Works with colleagues to eliminate avoidable days and denials

- Collaborates with colleagues to quickly address all potential financial losses identified through denial management processes

- Leads clinical cost reduction opportunities

- Executes cost reduction/containment strategies without adversely impacting patient care within the organization

- Identifies, studies and acts upon at least two significant clinical cost reduction activities per year in collaboration with physicians and possibly other clinical partners and reports work process barriers

- Collaborates with physicians and colleagues to develop a plan of action to promote appropriate utilization of resources across the continuum

- Anticipates and troubleshoots claim and reimbursement issues

- Provides feedback that will enhance payer negotiations

MHS Other

- Contributes to the success of the organization by meeting organizational competency expectations and core values (respect, integrity, stewardship, excellence, collaboration and kindness), continuously learning, and by performing other duties as needed or assigned

- Adheres to MHS Attendance and Punctuality Policy and Procedure standards. Maintains reliable attendance


- Respect: Seek first to understand

- Integrity: Do the right thing

- Stewardship: Live lean
..... click apply for full job details

Keywords: MultiCare, Seattle , Registered Nurse (RN), Healthcare , Auburn, Washington

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