Care Manager - Registered Nurse

Care Manager Registered Nurse (RN)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 - Non-Exempt - Salary Range - $38.46-$52.88Reports To - Medical Management Director - Direct Reports - YesLocation - Remote Los Angeles, CA - Travel - Up To 50%Work Type - Regular - Schedule - Part TimeDuties and Responsibilities (including but not limited to)Evaluates patients for care management services, determines appropriate level of care coordination management for the patientComplete a comprehensive assessment to identify patient risk and develop a care plan utilizing clinical expertise and judgement to evaluate needs for alternative services as neededWork 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 goalsMonitor and update care plan to include progress towards achieving established goals and self-management activitiesInteract 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 teamCoordinate necessary referrals and authorizations within care management areasFacilitate the information flow between hospitals, long-term care, specialists and home health representatives and the care teamUse available data and work with physician and office staff to help identify high risk, high need, and potentially high-cost patientsCoordinate 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 possibleVerify 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 assignedQualifications or Education, Training and ExperienceRN License – California Licensure preferred in additionBachelor's degree in nursing preferred; Associate degree in nursing is minimum requirement.1-2 years' experience in acute inpatient, rehabilitation, sub-acute, skilled facility, home care, ambulatory care management, or managed health plan.Preferred: Certified Case Management (CCM) certificationPreferred: Care/Case Management experienceWorking knowledge of the following required:Principles of utilization management; care management principles; basic knowledge of health plan contracts and benefit eligibility requirements; Hospital structures, Managed Care and payment systemsTimely and accurate documentation of day-to-day activities in designated technology platformAdaptable to new technologies and softwareProficiency in EMR system(s), Outlook and data entry experience preferredBasic PC skills (MS Word/Outlook/PPT/Excel)Examples of Competencies:Ability to use independent judgment and to manage and impart confidential information.Ability to analyze and solve problems; requires details, data and facts that must be analyzed and challenged prior to making decisions.Strong communication and interpersonal skills.Ability to clearly communicate medical information to professional practitioners and/or the public.Excellent organization, prioritization, follow up, analytical and time management skills with ability to handle multiple priorities and deadlines.Good interpersonal skills, sense of urgency, being proactive and ownership for one's work.Dependable, with strong work ethic and extremely high degree personal integrity.Ability to deal with multiple interruptions on a continual basis that must be met with a friendly exchange with others.Ability to develop and implement new approaches to improve processes, procedures, or the general work environment.Ability to review critical issues, effectively solve problems and create action plans.Work EnvironmentRequires in home visits with patients roughly 50% of the timeOtherwise based in LA officeBenefits:As a firm passionate about health care, we're deeply committed to the health and wellness of our own team members. We offer comprehensive, affordable insurance plans for our team and their families, and a host of other unique benefits, such as a yearly stipend for wellness-related activities, and a paid parental leave program.