Population Health RN Inpatient Case Manager

NorthBay Health•Fairfield, CA

23h•$80 - $96

About The Position

The Population Health RN Inpatient Case Manager provides complex case management to diverse groups of high-risk capitated populations. The role coordinates care and services for members navigating the healthcare system, supporting delivery of appropriate care across the continuum in collaboration with members, caregivers, medical home providers, and ancillary healthcare providers. Using a population health approach, the position helps identify populations, improve member engagement, coordinate care, and enhance clinical outcomes. The role also assists the inpatient case management department as needed. The case manager identifies high-risk patients, assesses clinical and social needs, develops and implements individualized care plans, and coordinates services with patients, families, providers, and interdisciplinary teams. The position supports health education, advocacy, care transitions, discharge planning, and continuity of care. It monitors outcomes and participates in quality improvement and performance review activities.

Requirements

Graduated from an accredited nursing school or college.
Bachelor of Science in Nursing (BSN) required.
Current California State RN License required.
Obtain Certified Case Manager (CCM) or Accredited Case Manager (ACM) certification within two years of starting the position.
At least two years of relevant clinical experience.
At least one year of case-management experience; equivalent case-management education and/or experience will be considered.
Computer skills, including entering and retrieving data, experience with Microsoft Suite—specifically Word—and/or good keyboard skills.
Ability to communicate effectively with patients, physicians, healthcare personnel, supervisory staff, and peers.
Strong organization and prioritization skills, with the ability to manage assignments efficiently with minimal oversight and direction.
Willingness to research, learn, and acquire knowledge needed to perform the position.
Professional and courteous demeanor and ability to collaborate effectively while maintaining positive relationships.
Critical-thinking skills and sound clinical judgment and assessment skills.
Knowledge of NCQA, DHS, CMS, JCAHO, and EMTALA standards and federal and state regulations.
Knowledge of acute, home, subacute, long-term, and hospice care; rehabilitation options; and community resources and requirements.
Knowledge of Milliman and InterQual medical-necessity guidelines.
Expert knowledge of CPT and HCPC codes and related guidelines.
Expert knowledge of ICE guidelines governing TAT, claims, and the denial process.
Knowledge of current healthcare standards and trends, best practices, management tools, and related resources and literature.
Knowledge of capitation and managed-care legislation.
Knowledge of CMSA Standards of Practice.
Demonstrate NorthBay Health’s True North Values: Nurture Care, Own It, Respect Relationships, Build Trust, and Hardwire Excellence.

Nice To Haves

Master’s degree in nursing or another health-related field preferred.

Responsibilities

Identify patients at high risk for medical care resource utilization by reviewing EHR referrals and information from the ED, Pharmacy, Hospital, and other departments or systems.
Assess members’ needs and develop care plans addressing identified objectives, barriers, and goals.
Identify patients’ strengths and opportunities, including physical, behavioral, social-support, and provider-engagement factors.
Follow up with patients and providers regarding healthcare needs and coordinate resources or multidisciplinary support.
Manage referrals from referral specialists, providers, and care management staff to ensure red flags and healthcare needs are addressed.
Provide individual and group health education to improve health awareness and support better health choices.
Provide oversight of care-plan implementation and patient education in accordance with established policies and procedures.
Identify at-risk individuals, apply clinical guidelines, gather and evaluate medical, psychosocial, and financial information, and advocate for patients and families throughout care.
Coordinate with patients, families, physicians, and interdisciplinary teams to develop and revise individualized plans of care, remaining involved until planned functional-health or closure criteria are met.
Provide patients and families with information about appropriate providers and involve their support systems in care decisions.
Assess patient understanding, acceptance, readiness for change, and support for maintaining health behavior changes; apply teaching and learning theories to address chronic illness and its physical and emotional effects.
Document and communicate with providers and care-team members to minimize fragmented care, including during transitions from hospital to home or community facilities.
Use problem-solving and conflict-resolution skills to provide consistent quality care and participate in department quality monitoring, audits, training, and projects.
Evaluate case-management effectiveness in relation to patient outcomes, fiscal parameters, customer satisfaction, and system operations; communicate performance-improvement strategies to the UM Manager and Director of Care Management as appropriate.
Manage inpatient care in collaboration with physicians and healthcare providers, develop comprehensive plans with physicians, Social Services, and the interdisciplinary team, and advocate for patients and families.
Track patient pathways through DRG identification and assignment; communicate anticipated discharge dates; reassess patients throughout their hospital stay and develop alternative discharge plans as needed.
Coordinate transition to the next appropriate level of care, involving outpatient case management or other resources, and remain involved until hospital discharge or transfer of case-management responsibility to outpatient services.
Perform other duties as assigned to meet the needs of the population managed.

Benefits

Medical insurance
Dental insurance
Vision insurance
Life insurance
Disability coverage
Long-term care coverage
Paid time off, including vacation, sick leave, holidays, and bereavement
403(b) retirement plan with employer match
Education reimbursement for eligible roles
Professional development and training programs
Employee Assistance Program
Wellness programs
Recognition programs
Shift differentials
Market-based compensation review and increases subject to approval and organizational performance