RN Care Manager

Institute on Aging•Inland Empire, CA

16h•$102,000 - $110,000

About The Position

IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative models transform lives, enhance communities, and save healthcare systems millions of dollars. Rather than focusing on archaic outdated design, we strive to consistently question the “status-quo” and create new and more innovative ways to help aging adults and adults with disabilities maintain their quality of life. With over 23 programs, we offer multiple ways to aid seniors maintain their health, well-being, independence and participation in the community, fulfilling our mission. IOA's Community Living Services division is an innovative and revolutionary healthcare model that allows seniors and adults with disabilities to live at home longer by transitioning them out of nursing homes and back into the community by partnering with health plans and Medi-Cal. This inventive, nationally recognized model is one of the most promising for seniors to date, transforming their lives by providing them with a higher quality and more independent life and saving millions of dollars for healthcare systems. CLS is IOA’s fastest growing division, expanding throughout California. The HCBA Medi-Cal Waiver program within Community Living Services division provides care management services to persons at risk for nursing home or institutional placement. The care management services are provided by a multidisciplinary care team comprised of a nurse and social worker. The care management team coordinates Waiver and State Plan services (e.g., medical, behavioral health, In-Home Supportive Services, etc.), and arranges for other available long-term services and support available in the local community. Care management and Waiver services are provided in the Participant’s community-based residence. This residence can be privately owned, secured through a tenant-lease arrangement, or the residence of a Participant’s family member. IOA is seeking a full-time Case Manager/Registered Nurse (RN). The Case Manager/RN will conduct comprehensive nursing health assessments of participants’ medical needs, diagnose functional and cognitive abilities and environmental and social needs to determine which service(s) are required to meet participants’ needs and preferences in the community. This position requires driving throughout Riverside and San Bernardino County depending on your assigned area with occasional cases out of your region. Other key duties and responsibilities include, but may not be limited to the following: Documenting assessment, case notes, care coordination, and utilization management within MedCompass, a population health management software Working with the participants, their legal representatives, circle of support, and primary care physicians develop goals associated with the participant’s assessed needs, individual circumstances, and preferences Develop a Plan of Treatment (POT) to mitigate risk and minimize disruptions in services identify when services identified in the POT are available through friends, family, and/or publicly funded programs implement the POT, which includes identifying service providers and community resources to help assure the timely, effective, and efficient mobilization and allocation of the services Identify (and train, if necessary), backup caregivers who are willing and able to provide unpaid support when waiver service providers do not arrive when scheduled. Providing information, education, counseling, and advocacy to, and on behalf of participants Establishing a care coordination schedule based on the needs and acuity of the participant as determined by their initial service needs assessment and subsequent reassessments Monitoring the delivery of HCBA Waiver services to ensure participants are receiving services as authorized in their POTs Monitoring the quality of the authorized services by maintaining ongoing contact with participants - including a monthly face-to-face visit or telephone call - to monitor for changes in health, mood, social integration, functionality, and overall well-being Conducting annual face-to-face visits, reassessments, and care plan updates Following up with the participant after Emergency Department and In-patient facility admissions

Requirements

Current, unencumbered license to practice as an RN in the State of California
Current Basic Life Support (BLS) certification
A minimum of 1000 hours of experience in the previous two years, in an acute care hospital caring for individuals with the care need(s) of individuals at the levels of care specified in this waiver
A valid driver's license and proof of insurance OR A minimum of 2000 hours of experience in the previous three years in an acute care hospital caring for individuals with the care need(s) of individuals at the levels of care specified in this waiver
A minimum of 2000 hours of experience in the previous five years working for a licensed and certified home health agency caring for individuals with the care need(s) of individuals at the levels of care specified in this waiver
A minimum of 2000 hours of experience in the previous five years in an area not listed above, that in the opinion of DHCS, would demonstrate appropriate knowledge, skill and ability in caring for individuals at one or more of the levels of care specified in this waiver
Experience establishing short and long-range goals for patient care which contribute to a continuum of care focus, and patient care will be delivered in accordance with the professional nursing process, which resulted in the delivery of quality patient care
Experience with, and understanding the medical diagnoses and medication associated with functionally impaired adults and older adults
Exceptional communication and presentation skills relating to functionally impaired adults and older adults, their support systems and teams of health professionals
Demonstrated case management experience and skills within the community health care delivery system
Excellent detail orientation and problem-solving skills
Demonstrated ability to prioritize multiple critical tasks
Excellent Computer literacy

Nice To Haves

Experience working with individuals with mental and/or behavioral health diagnoses and substance abuse disorders
Exceptional interpersonal, oral and written communication skills

Responsibilities

Documenting assessment, case notes, care coordination, and utilization management within MedCompass, a population health management software
Working with the participants, their legal representatives, circle of support, and primary care physicians develop goals associated with the participant’s assessed needs, individual circumstances, and preferences
Develop a Plan of Treatment (POT) to mitigate risk and minimize disruptions in services identify when services identified in the POT are available through friends, family, and/or publicly funded programs implement the POT, which includes identifying service providers and community resources to help assure the timely, effective, and efficient mobilization and allocation of the services
Identify (and train, if necessary), backup caregivers who are willing and able to provide unpaid support when waiver service providers do not arrive when scheduled.
Providing information, education, counseling, and advocacy to, and on behalf of participants
Establishing a care coordination schedule based on the needs and acuity of the participant as determined by their initial service needs assessment and subsequent reassessments
Monitoring the delivery of HCBA Waiver services to ensure participants are receiving services as authorized in their POTs
Monitoring the quality of the authorized services by maintaining ongoing contact with participants - including a monthly face-to-face visit or telephone call - to monitor for changes in health, mood, social integration, functionality, and overall well-being
Conducting annual face-to-face visits, reassessments, and care plan updates
Following up with the participant after Emergency Department and In-patient facility admissions