Population Health Management Case Manager RN I

Kern Family Health Care•Bakersfield, CA

4d•Onsite

About The Position

Kern Family Health Care (KFHC) is dedicated to improving members’ health through an integrated managed health care delivery system. Under the direction of the PHM Case Management Supervisor RN, the Population Health Management Case Manager RN I provides complex case management to diverse groups of high-risk Medicaid populations. Complex case management involves coordinating care and services for members who need assistance navigating the health care system, helping ensure they receive appropriate care and services in the right setting and at the right time. Services are provided across the continuum of care and in collaboration with members, caregivers, medical home providers, and ancillary health care providers. KFHC uses a Population Health approach to identify diverse groups, enhance member engagement, and coordinate care across populations to improve clinical outcomes. The position requires competence in basic and complex case management and advanced judgment. Case Managers work independently under general direction and communicate frequently with members, caregivers, medical providers, and KFHC staff by telephone, electronically, and potentially in person.

Requirements

Active, current, unrestricted California Registered Nurse license.
Associate Degree in Nursing required.
At least 2 years of full-time clinical experience in acute care, a community health setting, public health nursing, or chronic disease management.
Experience working with patients and caregivers regarding self-care and disease management.

Nice To Haves

Bachelor’s Degree in Nursing.
Experience working in case management or care coordination.
Knowledge of Kern County community resources for seniors and people with disabilities.
Bilingual English/Spanish.

Responsibilities

Identify members at high risk for medical care resource utilization by reviewing referrals and information from Health Risk Assessments, physicians, other medical providers, or family, and assess their needs.
Conduct assessments to identify member needs and develop specific care plans addressing objectives, barriers, and goals identified during the assessment.
Coordinate and manage care across the continuum, including outpatient care, medical home providers, and ancillary services.
Provide education and coordinate outpatient care for KFHC members selected for Case Management.
Identify and refer quality-of-care, coordination-of-benefits, and third-party-liability issues as appropriate.
Develop collaborative action plans with clearly identified, achievable objectives focused on modifiable risk factors.
Complete and document initial case management assessments according to departmental processes.
Participate in care management conferences and collaborate with team members and community providers.
Document care plan notes thoroughly and in a timely manner in accordance with professional standards and departmental processes.
Communicate, consult, and collaborate with the KFHC Medical Director as needed.
Serve as a liaison to community providers and KFHC members.
Communicate in writing and verbally with contract providers and KFHC staff to promote appropriate and timely coordination of care.
Perform other related duties and special projects as assigned.