Job Description
We are a community-focused health and care partner dedicated to enhancing the health and well-being of individuals who need support the most, especially within Black and Brown communities. Our dedicated team of local physicians, nurses, and caregivers collaborates to provide holistic care that goes beyond merely treating symptoms. We believe in breaking down barriers to deliver personalized care as close to home as possible, often in the comfort of our Family Members' homes. By understanding the unique backgrounds, cultures, and environments of those we serve, we aim to achieve better health outcomes. Together, we strive to make health and care a reality for everyone, every day. Join us in creating a better way to care!
About You
We are seeking a compassionate RN Case Manager with the following qualifications:
Education: A valid Registered Nursing license in California and a Bachelor of Science in Nursing (BSN) is required.
Experience: At least 5 years of relevant clinical experience, with 3+ years in care management within health plans, home health, or hospice settings being ideal.
Entrepreneurial Spirit: We seek someone who can identify and address longstanding gaps in care delivery for underserved populations. The ideal candidate will work independently and be proactive in initiating positive changes.
Communication Skills: Strong verbal and written communication skills are essential. You should be able to convey concepts clearly and present information in an accessible manner.
Relationship Building: The ability to foster and maintain effective relationships with patients, community leaders, and external partners is crucial.
Cultural Fit: Good judgment, impeccable ethics, and a collaborative spirit are essential. We value individuals who are eager to grow and thrive in a fast-paced, dynamic environment.
About the Role
As the RN Case Manager, you will report to the Director of Clinical Operations and be responsible for providing strategic guidance, organization, and evidence-based analysis to influence decisions that meet our community's needs. You will embody our core values of trust, empathy, commitment, humility, creativity, and community focus.
Responsibilities
Collaborate with an interdisciplinary team to ensure high-quality outcomes for our members and their families dealing with chronic diseases.
Develop care pathway templates based on specific conditions, risk levels, and necessary member actions.
Create Member Action Plans using care pathway templates for high-risk chronic conditions.
Utilize remote patient monitoring and patient self-reporting tools to support members effectively.
Conduct in-home or telehealth assessments as needed.
Respond promptly to member alerts and maintain active communication through texts and calls.
Monitor remote patient data and notify the care team of any concerning results or clinical outcomes.
Provide comprehensive care coordination, including patient navigation, chronic disease education, and interdisciplinary collaboration, while adhering to policies and contractual requirements.
Work with patients and their care teams to create Member Action Plans that prioritize individual needs, and track progress while reassessing as necessary.
Engage patients in managing their health, treatments, and follow-up care, and refer them to appropriate community resources.
Follow evidence-based guidelines to close gaps in care and determine the need for in-home services.
Use electronic medical records and care management platforms to conduct coordination activities and ensure compliance with documentation standards.
Participate in team rounds to contribute to ongoing program design and process improvement initiatives.
Reassess Member Action Plans after discharge to ensure continuity of care.
Demonstrate the ability to adapt to changing priorities and effectively manage a patient care load.
Collaborate daily with the interdisciplinary team to discuss care planning and facilitation.
Perform other job-related duties as assigned.
Additional Duties
Leadership: Lead in defining and executing strategies that create value within clinical practice, working closely with your team to develop and implement effective solutions.
Strategy Development: Establish and implement strategies to improve outcomes for our members, enhance operational efficacy, and explore market opportunities for our services.
Collaboration: Ensure that clinical capabilities are cohesive by working closely with other business divisions to understand their needs and define solutions that meet collective goals.
Knowledge Sharing: Provide expertise in clinical solutions and recommend approaches for delivering high-quality medical care.
Culture Building: Foster a productive, collaborative, safe, and inclusive environment for the clinical team.
Working Environment
This position involves both in-home and office-based work, requiring frequent travel for home visits and meetings with healthcare providers and community partners in various weather conditions. Office work is conducted in a traditional setting with controlled conditions.
You should be able to travel regularly by car or public transportation and communicate effectively with a range of stakeholders, sometimes in challenging situations. Proficiency in using telephones and email is essential, as is the ability to sit for extended periods and lift up to 30 lbs occasionally. Strong reasoning skills and the ability to understand and utilize management reports and documents are also important.
Employment Type: Full-Time
Salary: $ 86,000.00 90,000.00 Per Year
Job Tags
Full time, Local area, Remote job, Home office,