RN Coordinator ECM - Ambulatory

MLK Community Healthcare is seeking a Registered Nurse (RN) Coordinator to be part of our MLKCH Enhanced Care Management program. The RN Coordinator will be responsible for coordinating the care of patients enrolled in MLKCH's ECM program. They will be active members of the Interdisciplinary Care Team meetings to discuss medication management/adherence, ensure appropriate follow-up with Primary Care Provider, Behavioral Health Provider, and other specialist(s). This position is also responsible for conducting nursing assessments, behavioral health, and social service needs, developing care plans, coordinating care, and working with the team's medical provider to support the patient's health goals. This is a dynamic position requiring a combination of excellent leadership, clinical, and patient engagement skills. The RN Coordinator is essential to organizing the workflows for the team by prioritizing patient care based on acuity and complexity, resources available to support patients, and the diverse skill sets of the other team members. The RN Coordinator works with a variety partner organization by providing transitional healthcare until a patient has stabilized enough to transition to other systems of conventional care (e.g., primary care and/or a community mental health clinic, housing) or has been placed in a higher level of care.

• Provides Clinical Oversight of ECM Lead Care Managers to address the patient's medical and behavioral health needs. Participates in developing patient-centered care plans for the enrollees on their panel. (RN Coordinator will have a patient panel of 15-20 patients)
• Ensures that ECM members are receiving needed services and measuring progress towards the goals outlined in their patient-centered care plan
• Oversees quality measures to ensure the optimal care is given across access, clinical, and experiential benchmarks.
• Assists in identifying health care needs that focus on general health conditions, treatments, and interventions specific to each individual's health needs and consistent with standards of care.
• Actively consults with Care Managers to review medical visit summaries, discharge papers, prepare for upcoming appointments, or review appointment outcomes
• Provides health and preventive care education for acute health conditions, chronic disease management, and medication monitoring.
• Engages vulnerable populations as part of a multidisciplinary outreach team. This includes home visits, accompaniment to appointments, outreach to hospitals, homeless shelters and other settings, as needed.
• Helps address Social Determinants of Health and enhances connections to community-based organizations
• Works with hospitals to coordinate hospital admission/discharge plans with the behavioral health clinician, PCP, pertinent specialists, and other organizations with the goal of preventing readmission, if possible.
• Performs timely medication reconciliation following transitions in care. Supports medication adherence.
• Assists with billing submission.
• Assists with health plan Chart audits.
• Performs other duties as assigned or requested.

• BSN preferred.
• Current Registered Nurse California state license.

• Minimum of one (1) year of case/care management experience required. Candidates with combined care/case management and nursing experience will be considered.
• Demonstrated experience building effective, strong relationships with peers and leaders

• Current Basic Life Support (BLS) for Health Care Providers from the American Heart Association
• Current Advanced Cardiac Life Support (ACLS) for Health Care Providers from the American Heart Association, preferred
• Must complete annual Workplace Violence Prevention Program/Certificate, per hospital policy, during initial training/orientation but not to exceed 30 days from hire/transfer.
• Valid unrestricted CA Driver's License to drive company vehicle.
• Relevant experience in understanding homelessness, and in promoting community relations (preferred)
• Demonstrated ability in providing services for people experiencing homelessness (preferred)
• Demonstrated ability to build consensus on strategies among peers to address homeless patients (preferred)
• Ability to effectively coordinate care with medical assistants and other support staff, encourage and nurture development and growth, to build a strong and productive team, preferred
• Commitment to the provision of primary care services for the underserved with demonstrated ability and sensitivity in working with a variety of people from low-income populations, with diverse educational, lifestyle, ethnic, and cultural origins
• Strong organizational, administrative, and problem-solving skills and ability to be flexible and adaptive to change
• Ability to effectively present information to others, including other employees, community partners, and vendors
• Ability to seek direction/approval on essential matters yet work independently with little supervision, using professional judgment and diplomacy
• Work in a team-oriented environment with several professionals with different work styles and support needs
• Demonstrated ability to interact effectively with people on the streets and at all levels of the organization (preferred)
• Demonstrate ability to work with unsheltered homeless, their environment and their social issues (preferred)
• Ability to demonstrate knowledge of public health care systems (preferred)

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