MSO Case Manager

MSO Case Managers are licensed nursing professionals responsible for coordinating continuum of care and discharge planning activities, developing individualized person-centered care plans and goals, and facilitating case conferences among all service providers for a caseload of assigned patients. MSO Case Managers act as a consultant to the clinical team, service lines, and other departments regarding patient assessment and patient care, and participate in program development and quality improvement initiatives. The MSO Case Manager collaborates with other interdisciplinary team members and influences the delivery and quality of patient care. The objectives are to facilitate timely discharges, prompt and efficient use of resources, achievement of expected outcomes, collaborative practice, coordination of care across the continuum, and performance/quality improvement activities that lead to optimal patient outcomes. ESSENTIAL JOB FUNCTIONS: Functions as a resource to non-licensed team members and collaborates with physicians, social workers, nurses, and other interdisciplinary team members to assess, plan, and coordinate patient care needs. Assists in developing individualized plan of care to ensure consistent, timely, and appropriate care is provided in a patient-focused manner. Identifies patient’s own strengths and barriers in meeting care plan goals, supports patients and caregivers in re-assessment and modification of care plan goals. Initiates and participates in care conferences to involve patient’s primary care provider, specialists, social worker, and community care coordinator to provide input to patient’s plan of care, and to ensure patient’s care is continuous and integrated along all service providers. Co-manages each patient’s transition through the managed care delivery system and facilitates transfers of accountability to the appropriate party upon entry into another clinical service or discharge. Coordinates and facilitates timely discharge plans for assigned patients with complex needs, including follow-up care arrangements as appropriate. Monitors patient’s hospital length of stay and collaborates with MSO Utilization Management (UM) team and PCPs to ensure resource utilization are appropriate in relationship to the patient’s clinical and psychosocial needs. Acts as an educational resource and provides supervised consultation to patients and their families regarding the case management program goals. Identifies resources and eligibility criteria for housing, food security, nutrition, employment counseling, childcare, community-based support services, school and faith-based services, and disability services, as needed and desired by patients and their families to support their ability to self-manage and meet health goals. Utilizes multiple systems and applications to develop and maintain appropriate documentation of assessments, care plans, discharge arrangements, and actions taken according to regulatory guidelines. Collects, analyzes, and reports data for utilization management, quality improvement, compliance, and other areas as assigned. Performs direct medical care, such as injections and vaccinations, as needed. Performs other job duties as required by manager/supervisor. QUALIFICATIONS: Valid California Licensed Vocational Nurse (LVN) Current documentation of Basic Life Support is required. Valid Driver’s License and ability to maintain license preferred. Demonstrate willingness to make decisionswithinthe license’s scopeofpractice;exhibitsound,accurate, and ethicaljudgment. Abilityto engage andworkcollaborativelywithothers,includingpatients,patient'sfamilies,clinicalteammembers, clinical supervisors,andcommunity resources. Ability to provide detailed,concise note/documentation of workwithin workflow turnaround timelines. Basic medical knowledge, including the ability to observe safety and security procedures, andrecognize trauma symptoms and behaviors. Good communication and interpersonal skills; ability to work with people from diverse backgrounds and experiences. Able to spend 20-40 minutes at a time with patient in the community, including at clinics, specialist offices, hospitals, community-based organizations, or patient’s home which may be in understaffed/remote areas, in the presence of pets or family members that are tobacco users. Time management and prioritization skills are vital. LANGUAGE: Must be able to fluently speak, read and write English. Fluent in Chinese (Cantonese and Mandarin) required. Fluent in other languages is an asset. STATUS: This is an FLSA Non-exempt position. This is not an OSHA high-risk position. NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k). #J-18808-Ljbffr