Care Manager – Registered Nurse

The Care Manager Registered Nurse (RN) serves as a key clinical member of the interdisciplinary care team as part of the Care at Home Solutions program. The Care Manager RN partners closely with the Medical Director, Advanced Practice Provider (APP), Licensed Clinical Social Worker (LCSW), Community Health Worker (CHW), Pharmacist, and Care Navigators to coordinate care for patients with complex medical, behavioral, and social needs.

The Care Manager RN develops and implements individualized care plans, provides clinical assessment and education, conducts telephonic and in-home care management visits as appropriate, supports transitions of care, and collaborates with primary care providers to improve quality, patient experience, and health outcomes. The Care Manager RN plays a critical role in reducing avoidable utilization, addressing barriers to care, and helping patients successfully manage chronic conditions.

• FLSA Status:
  Exempt
• Salary Range: $80,000-$110,000
• Reports To:
  
  Medical Management Director
• Direct Reports:
  Yes
• Location:
  
  Hybrid; LA office
• Travel:
  Up to 50%
• Work Type:
  Regular
• Schedule:
  
  Full Time

(including but not limited to)

• Evaluates patients for care management services, determines appropriate level of care coordination management for the patient
• Complete a comprehensive assessment to identify patient risk and develop a care plan utilizing clinical expertise and judgement to evaluate needs for alternative services as needed
• Work collaboratively with physicians and in-house resources including pharmacists, registered dieticians, social workers and other disciplines to create a person-centered care plan with measurable SMART goals
• Monitor and update care plan to include progress towards achieving established goals and self-management activities
• Interact with patient, family and providers and interdisciplinary care team to assess the options of care including use of benefits ad community resources to update care plan. Utilize developed systems, processes, and initiatives to engage patients in relevant case management activities necessary to promote wellness and care at the right place and time.
• Work collaboratively with physicians and in-house resources including pharmacists, registered dieticians, social workers and other disciplines to support patient adherence to medical plan of care.
• Supervise and act as a resource for non-clinical staff [i.e. care coordinators, social workers].
• Verify that appropriate home care, hospice care, and other ancillary services (DME, infusion services etc.) are in place and are being delivered as directed by the care team
• Coordinate necessary referrals and authorizations within care management areas
• Facilitate the information flow between hospitals, long-term care, specialists and home health representatives and the care team
• Use available data and work with physician and office staff to help identify high risk, high need, and potentially high-cost patients
• Coordinate care and communicate with multiple providers, internal and external to the practice.
• Identify and utilize cultural and community resources and align with the patient’s cultural preferences as much as possible
• Verify that members are screened for behavioral health concerns (depression / substance abuse) and are receiving appropriate screening and behavioral health interventions.
• Facilitate any necessary follow-up behavioral health needs with local behavioral health providers.
• Attend required training and collaboration sessions [i.e., learning sessions, care management meetings, and practice team meetings] as scheduled.
• Provide and facilitate open communication, regarding patient status, with physicians and office staff.
• Obtain records from other physicians/labs/diagnostic centers as requested by the physicians and as needed for care coordination efforts.
• Develop constructive relationships with internal population health team members, participating providers, and community resources.
• Other job-related duties as assigned

• RN License – California Licensure preferred in addition
• Bachelor’s degree in nursing preferred;
  Associate degree in nursing…