Kaiser Permanente RN, Adult Foster Home Care Coordinator - PC@Home (Montgomery Park) in Portland, Oregon

Serve as the primary contact for Adult Foster Home (AFH) providers and members residing in the cachment area for Kaiser Permanente AFHs. Assess the needs of these members and the AFH caregivers and facilitate the delivery of appropriate health care services in the most efficient and effective setting. Provide telephone advice and case management for Kaiser Permanente members residing in adult foster homes.

Essential Functions:

  • Act as a liaison between the Kaiser Permanente care delivery system and AFH caregivers to assure member services are managed effectively and efficiently and proper levels of care are achieved.

  • Assure accurate, understandable telephone information and medical advice is given to members, their families and AFH caregivers regarding health problems after assessing the situation, reading the medical record and/or consulting with staff and clinicians.

  • Assure Geriatric Long Term Care (GLTC) clinicians have thorough, accurate information to support them in providing care to members living in AFHs (such as health and medical history, current clinical and social situation, AFH-specific situations and needs).

  • Assess information provided by the patient, family and/or AFH providers and make a determination of acuity of problem and need for home visit by a GLTC clinician. Provide telephone follow-up to assess patient stability as needed and directed by GLTC.

  • Assess adequacy of AFH caregiving plan and make recommendations to GLTC providers, family and AFH provider to improve and enhance patient's health.

  • Work with GLTC administrative assistant in scheduling home visits to members residing in AFHs by GLTC clinicians.

  • Develop, implement and maintain policies, procedures and processes in support of the AFH project utilizing staff expertise from GLTC, CCS, outpatient and inpatient staff and care coordinators. Establish effective working relationships with those identified as critical to program success. Gather data needed to effectively advocate for enhancements in the health care delivery system for the AFH population.

  • Perform other duties as requested.

Basic Qualifications:


  • Minimum four (4) years of experience as a nurse.


  • BSN or commensurate knowledge and experience.

License, Certification, Registration

  • Current Oregon and Washington RN license required. License in state where assigned required upon hire/transfer, application for license in secondary state required within 2 weeks of hire/transfer and must be obtained within 6 months.

  • Drivers Licenses required upon hire/transfer.

  • Basic Life Support (BLS) for Health Care Providers required upon hire/transfer.

Additional Requirements:

  • Knowledge of Kaiser Permanente Health care system.

  • Knowledge of community resources in both OR and WA.

  • Knowledge of regulations governing AFHs, home health, hospice and nursing facilities.

  • Knowledge of care and case management.

  • Knowledge of Word, Excel, OA.

  • Knowledge of medication usage, particularly pain/symptom management.

  • Knowledge of normal/abnormal lab values.

  • Demonstrate customer-focused service skills.

  • Effective verbal and written communication skills.

  • Ability to organize work and thoughts.

  • Effective interpersonal communication skills.

  • Ability to prioritize patient needs accurately.

  • Excellent time management skills.

  • Excellent problem-solving and triage skills.

  • Well-developed key boarding skills.

  • Ability to learn Kaiser Permanente automated systems including EPIC, KARE, ADT.

Preferred Qualifications:

  • Minimum two (2) years of home health or hospice experience.

  • Minimum four (4) years of experience as a registered nurse in medical/surgical or acute care.

  • Minimum one (1) year of experience in triage.

  • Experience working closely with physicians, nurse practitioners and other clinicians.

  • Experience in teaching adults or persons with English as a second language.

  • Case Management certification.

  • Working knowledge of managed care, home health, hospice home infusion, skilled nursing facilities and long term care and applicable regulations and standards.

  • Knowledge of utilization management principles and processes.

  • Knowledge of quality improvement processes.

  • Knowledge of health plan benefits and the application of such.

  • Knowledge of the principles of triage and advice nursing.

  • Knowledge of Kaiser Permanente wound care protocols.

  • Skilled in physical assessment.

  • Excellent interview skills.


TITLE: RN, Adult Foster Home Care Coordinator - PC@Home (Montgomery Park)

LOCATION: Portland, Oregon


External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.