The self-directed public health nurse provides home care services to Kaiser Permanente patients in community based and facility settings. This position may provide nursing services to patients in the home health, hospice, home infusion, palliative care, or other programs under the direction of the patient´s physician(s) to provide quality health care outcomes and facilitate the achievement of maximum independence of the patient utilizing health care resources within Kaiser Permanente and the community.Essential Functions: Provides nursing services to patients consistent with agency policy, state practice acts, and applicable state and federal regulations as directed by the patient´s physician Manages the care of patients from admission to discharge, coordinating the multidisciplinary plan of care: including appropriate referrals to other disciplines; community resources; supervision of the home health aid plan of care; coordination of the discharge plan and documentation to reflect all activities provided in program appropriate care settings Assesses the learning needs of the patient/caregiver to develop the plan of care that meets patient and family needs and goals including the provision of effective teaching, supervision and delegation of care to achieve desired health care outcomes and timely discharge consistent with quality care Partners with agency management in the development and review of programs within Continuing Care Services. Facilitates the initiation of cost effective home care and provides consultation to clinicians regarding appropriate care setting alternatives 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 Participates in hospice, home infusion, home health and palliative care call duty consistent with agency policy Participates in department quality management/improvement activities; including but not limited to clinical record review, occurrence reporting, focused studies, process and outcome measurement, peer review, continuous quality improvement projects, partners in defining and achieving agency productivity standards Performs other duties as requestedBasic Qualifications: Minimum 1 year medical-surgical nursing experience in an acute care setting Baccalaureate degree in nursing or commensurate knowledge and experience (Commensurate knowledge and experience may include recent experience in areas of care coordination, case management, community health, and public health) Licensed in Oregon and Washington. Requires license in primary state, Oregon, prior to first day of employment. Application for licensure in secondary state must be made within six (6) weeks of start date. Licenses in both states required within six (6) months of hire Valid driver´s license Basic Life Support CPR card for Health Care Provider. Valid card must be obtained prior to patient contact and within two weeks of hire Able to perform complete physical, psychosocial, spiritual assessments Able to operate stethoscope and sphygmomanometer Keyboarding or typing skills Able to learn to operate a laptop computer to perform clinical documentation. Working knowledge of concise, yet thorough clinical documentation of patient assessments and care Effective problem solving, written and verbal communication and organizational and time management skills required to accomplish case management responsibilities within allocated time frames Note: This position requires completion of a typing test Note: This position requires a reliable automobile to travel to and from patient homesPreferred Qualifications: - Operational knowledge of computerized clinical documentation and office application systems including the use of laptop/notebook computers - Working knowledge of the managed care industry - Knowledge of Medicare regulations/requirements - Excellent time management, problem solving and customer service skills- Excellent written and verbal communication skills. Able to work autonomously and manage patient caseload - Knowledgeable of the care for the chronically ill and frail elderly - Working knowledge of Hospice and palliative care for the terminally ill patient. Pediatrics, including well child care Oncology/hospice Rehabilitation nursing Hospice care and the dying process Peripheral and central line IV management - Able to perform venipuncture and IV insertion - Able to operate multiple IV pumps - Able to perform surgical debridement as part of wound care