Case Manager RN Complex Care Medicare Advantage

Sutter Health Santa Rosa , CA 95402

Posted 6 months ago

Sutter Pacific Medical Foundation is a not for profit corporation that exists to provide medical services, research and education. The foundation provides the infrastructure for the delivery of physician services, and contracts with a separate corporation comprised of physicians and other care providers to deliver the clinical services. This multi-specialty foundation will provide a platform from which new physicians can be recruited to continue to provide physician services in a nonprofit, community setting. The Foundation's vision is to create a medical group that will deliver high quality, market competitive medical services.

The ambulatory nurse case manager provides patient-centered case management to patients who have chronic diseases, complex medical conditions and who are in transition across the continuum of care settings, as an extension of the physician and primary care team.

The case manager serves patients ranging in age and developmental stages ( pediatrics to geriatrics) using the nursing process of assessment, planning, implementation and evaluation. As a member of an interdisciplinary team the case manager coordinates care in accordance with the plan of care, to achieve optimal results by impacting the delivery of quality care in a holistic approach to the patient and family.

  • Comprehensive nursing assessment of medical, social, mental health, cultural, and economic factors affecting a patient's health and quality of care

  • Documents case management activities and communications following department standard work within EPIC; evidenced by chart review of assessment, patient goals and plan of care, patient status, referrals and collaboration with primary physician and care team

  • Develop individualized patient care plans which are personalized to reflect the patient's values and goals to achieve optimum health.

  • Apply current case management principles and practice to support patient centric goals

  • Raise patient capacity to self-care. Promote patient self-determination and self care independence for health management

  • Deliver care through telephonic and face to face assessment, and telehealth Vidyo as most appropriate to meet the patient plan of care

  • Concurrent review, discharge planning, and care coordination between inpatient and outpatient settings to support transition of care goals of care

  • Demonstrates understanding of patho-physiology, rationale for treatment and educational factors for a wide variety of disease processes and body systems.

  • Coordinates delivery of services to deliver quality patient care; employing case management principles for the stewardship of resources and utilization of services


  • Interacts in a professional manner with co-workers, other staff and physicians to promote positive atmosphere in the department, demonstrates and support a professional collaborative relationship with staff peers, internal and external agencies.

  • Leads, and participates in interdisciplinary team meetings.

  • Participates in scheduled staff meetings, volunteers and participates in team development and department improvement projects and committees.

  • Reports patient condition to appropriate member of health care team in a timely manner.

  • Seeks medical director consultation and collaboration for the patient condition, plan of care and concerns.

  • Identifies and refers quality and risk management concerns following department and Sutter policies and tools.

Team Work and Professional Development:

  • Consistent with affiliate service standards; communicates and works in a professional, respectful, and positive manner as a member of the healthcare team

  • Provides training and mentoring and is a role model to other team members, establishes open communication and reporting to supervisor or manager

  • Accepts changing conditions and is flexible to alterations of established routines to meet patient care needs, department and organization goals

  • Maintains and updates own knowledge and skills as evidences by participation in continuing education and department training opportunities

In addition to the key accountabilities listed, employees working in this position are expected to accept and perform other duties as requested.

  • Sutter Pacific Medical Foundation does not require a Licensed Vocational Nurse (LVN) license.


  • Bachelors (BSN) from an accredited nursing program required


  • Registered Nurse
  • State Licensure

  • RN required

  • Licensed Vocational Nurse
  • LVN required
  • Certified Case Manager
  • CCM required or expected to attain CCM within two years of hiring
  • Driver License, Valid and in State
  • DL NUMBER required upon hire
  • Basic Life Support Certification
  • BLS required upon hire


  • Experience working in EPIC and EPIC TapestryWorking with patients with complex medical conditions or chronic diseases across the age spectrum required

  • Ambulatory care or Acute care nursing experience required

  • Case management, home care or discharge planning experience required


  • Microsoft office programs and Computer literacy skills. EPIC knowledge preferred

  • Organizational skills, prioritization and multitasking skills

  • Knowledge of the health care financial environment and requirements for various payer types, e.g., Commercial, CMS, CCS for HMO and PPO cases, and ability to apply Managed Care concepts

  • Experience coordinating care across disciplines and within the community; ability to coordinate community resources

  • Knowledge of applicable NCQA standards, state and federal regulations

  • Self-starter who can work independently without close supervision and who ensures management staff are kept aware of any issues

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Case Manager RN Complex Care Medicare Advantage

Sutter Health