Reporting to the Community Care Manager, and as a member of the Care Management Team, the Community Care RN coordinates an interdisciplinary approach to support continuity of care. This role develops and monitors the plan of treatment for a caseload of Community Care Management program participants, and provides community-based (in-home and telephonic) care management services to ensure the health, safety, and well-being of vulnerable and high-risk populations. This includes providing utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed by members.
This position works closely with all members of the Care Management Team to develop, evaluate, and monitor service and care coordination plans that have a direct impact on improved outcomes and cost containment.
Responsible for the proactive management of acutely and chronically ill patients with the objective of improving health outcomes and costs by developing a detailed plan of treatment that reflects an appropriate nursing assessment of the care management applicants, interventions, and the potential participant's primary care physician's orders.
Monitor patient outcomes and plan of treatment efficacy in accordance with mandated timeframes and program guidelines either telephonically or during an in-person home visit. Inform the primary care physicians of the participant progress. Assess quality and clinical risk issues on a concurrent basis; reporting any recognized issues according to program policy.
Develops strong working relationships with external contracted providers, case managers, and admissions department/personnel.
Assess documentation of medical records for completeness and relationship to the treatment plan and identifying gaps or barriers in treatment plans.
Facilitates on-going communication between staff and contracted providers to ensure authorizations are secured in a timely and efficient process.
Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the facilities and service providers.
Participates in Utilization Management team meetings, as needed, reviews and discusses with providers evidence based care options and proposes alternative levels of care.
Conducting a comprehensive health and psychosocial assessment of participants' medical needs, diagnosis, 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.
Working with the participants, their legal representatives, circles of support, and/or primary care physicians and providers to:
Develop goals associated with the participant's assessed needs, individual circumstances, and preferences.
Mitigate risk and minimize disruptions in services.
Identify when services identified in the POT are available through friends, family, and/or publically 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 if and when waiver service providers do not arrive when scheduled.
Provide 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 Community Care Management program 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; and, following up with the participant after Emergency Department and inpatient facility admissions.
Attend DHCS' meetings, teleconferences, and trainings; or ensure a knowledgeable proxy attends in the place of the program lead to ensure the transfer the information
Maintain accurate case management records and timely documentation standards.
Participates as a clinical consultant within the Homes Health Program to review and inform regarding the participants health action plan, act as clinical resource for care coordinators, as needed; and facilitate access to primary care and behavioral health providers, as needed to assist care coordinators.
Additional Duties and Responsibilities
Works independently and as an effective member of the team.
Multi-tasking in regards to projects and their respective activities, timelines and issues.
Demonstrate ability to inter-relate with physicians, nurses, patients, internal departments, outside agencies, and the general public.
Demonstrate customer-focused service skills.
Knowledge of HMO and Waiver program regulations related to eligibility requirements and plan specifics.
Working knowledge of InterQual or other evidence based care guidelines.
Basic physical, psychosocial, and functional assessment skills.
Able to collaborate between organizational and community resources.
Thorough knowledge of appropriate utilization of acute hospital, long-term care and home care resources.
Able to document concise yet thorough clinical documentation of patient assessment and care needs.
Demonstrated strong communication and customer service skills, problem solving, critical thinking, time management, organizational skills and clinical judgment abilities. .
Familiarity and ability to use computers as well as EHR's.
Complies with all department, organization and government policies & procedures.
Attends meetings and trainings as required.
Adheres to and models SYH's core values and behaviors of Excellence, Empowerment, Integrity and Respect.
Adheres to SYH attendance and punctuality policies and practices.
Performs other duties as assigned
Education Required (Minimum level of education): Current CA RN License. Valid CA driver license and reliable transportation.
Preferred: BSN or MSN Degree
Certifications/Licenses Required: Current California RN licensure required. Current Basic Life Support (BLS) Certification CA valid driver's license and reliable transportation and proof of current vehicle insurance (if applicable)
Experience Required (Minimum level of experience):
2 years of experience working in a managed care health plan or
2 years of experience in utilization review, case management, and/or discharge planning or
2 years of experience in transitional care and acute care settings (critical care, acute hospital care, long term acute care, skilled nursing care, long term care)
Knowledge of and/or experience with Managed Care Health plans, Medi-Cal/Medicaid, and/or Medicare
Knowledge of managed care regulations (state and federal)
Principles and practices of health care service delivery, managed care, health care systems, and medical administration
Experience performing audits analyzing productivity and quality of utilization management
Knowledge and/or experience with the senior care market, including competitors, regulations, and available resources
Experience in the application of InterQual criteria or other evidence based medical criteria.
Technical Knowledge and Skills Required to Perform the Job: Must thrive within a team environment, possess good organizational skills, and have the ability to effectively handle difficult and unusual interpersonal situations. Good knowledge of Microsoft Applications including Word, Excel, Access and Power Point. Computer data entry, analysis and reporting experience required. Knowledge of Electronic Health Data Systems including NextGen and TruChart preferred.
Competencies: Demonstrated ability to be culturally sensitive and respect diversity, work effectively with individuals of different cultures and socio-economic status; passion for service; self-starter and highly organized; ability to prioritize and complete a large volume of work within strict deadlines; provide prompt, efficient and responsive customer service.
Equipment used: Personal vehicle, computers, phones, copy machines, fax machines and other general office equipment.
San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family.
The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 92,000 patients through a vast and integrated network of 34 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees.
Apply today and become a part of our mission-driven team!
San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment. Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to reace, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.
San Ysidro Health Center