Case Manager (RN/LIC)

UHS•Riverside, CA

19d•Onsite

About The Position

Under the general direction of the Director of Utilization Management, the Population Health RN Case Manager will coordinate team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician. This role focuses on improving the health status and care for individuals with chronic conditions; potentially complex medical, mental health, and psychosocial issues; and implementing the utilization review, clinical review plan approvals, discharge planning, and transitional case management processes. Duties will be performed in accordance with NCQA, federal, state, and local guidelines, organizational and departmental policies and procedures. Communicates with medical staff, other departments, and outside agencies while maintaining confidentiality.

Requirements

Current licensure as a Registered Nurse required.
Must possess strong clinical assessment and critical thinking skills necessary to develop a comprehensive plan of care appropriate to patients with complex medical, emotional and social needs.
Has the ability to work in a high-volume caseload environment and deal effectively with rapidly changing priorities.
Current, active, non-restricted California Registered Nursing License.

Nice To Haves

Two or more years’ experience in clinical or community health settings preferred.
Previous Care Coordination, Case Management or Home Health experience preferred.
Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.
Experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.
CCM Certification preferred.

Responsibilities

Provide a coordinated, strategic approach to identify new or manage an established chronically ill patient population
Stratify patient population according to risk to effectively and efficiently manage patients. Determine frequency of need for provider appointment and CCM encounters. Maximize use of qualified clinical staff within the care management team to provide appropriate non-face-to-face patient contact.
Collaborate with practice leaders to implement effective internal tracking systems for patients such as patient panels, annual wellness visit scheduling, and transition of care follow-up calls/timely provider visits, and CCM non-face-to-face monthly encounters.
Ensure all required elements are documented for CCM and related Annual Wellness Visits (AWV) component billing.
Collaborate with practice leaders to establish a method for assigning patients into a panel listing by provider that is routinely utilized for scheduling purposes and is continually monitored to balance supply and demand. Utilize empanelment method to ensure that preventive, chronic, and acute needs of all patients are met, including both high and low utilizers.
Ensure office staff has an effective internal tracking process to capture results, medication acquisition, missed appointments, and adherence to follow-up appointments.
Develop a process to track Annual Wellness Visits (AWV) scheduling and ensure that patient records are reviewed appropriate to identify care gaps prior to visit with the provider visit. Post reminders to secure that all co- morbidities are discussed and documented during AWV.
Participate in routine huddles with provider and care team. Identify scheduling opportunities, determine special needs for patients arriving that office/clinic day, identify patients who need care outside of their scheduled visit, patients overdue for AWV and those with missed appointments needing rescheduling. Ensure sharing of positive patient stories or compliments involving care team efforts.
Provide clinical health coaching interventions to motivate patients and families toward successful self-management of chronic disease. Effectively partner with provider practice team members to mobilize needed community resources for the patient and family.
In collaboration with the physician or qualified healthcare provider, develop a care plan based on mutual goals with the patient, family, the provider’s emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed.
Facilitate patient access to appropriate medical and specialty providers as indicated by physician or qualified healthcare provider.
Complete health risk assessments; perform medication reconciliation; assess social determinants of health and coordinate services as needed.
Provide Case Management support for assigned caseload of Medicare ACO beneficiaries and HMO members.