Registered Nurse- Care Manager

Community health is about more than just vaccines and checkups. It's about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We're with you every step of the way, with the care you need for each of life's chapters. At Neighborhood, we are Better Together.

As a private, non-profit 501(C) (3) community health organization, we serve over 414,995 medical, dental, and behavioral health visits from more than 87,099 people annually. We do this in pursuit of our mission to improve the health and happiness of the communities we serve by providing quality care to all, regardless of situation or circumstance.

We have been doing this since 1969 and it is our employees that make this mission a reality. Regardless of the role, our team focuses on being compassionate, having integrity, being professional, always collaborating, and consistently going above and beyond. If that sounds like an organization you want to be a part of, we would love to have you.

The RN Care Manager supports Enhanced Care Management (ECM) patients with complex medical conditions and completes medication reconciliation with pharmacies for all ECM-enrolled patients. This role will provide care coordination and connection to services and social support for ECM patients, including appointment scheduling and referral management. In addition, this role will require travel to Neighborhood Healthcare sites as needed for designated meetings and trainings.

Responsibilities

• Manages a caseload of patients with complex medical needs

• Engages, supports, and encourages patient activation towards achieving health goals

• Tracks medical and behavioral health outcomes in the web-based care management platform and patient electronic health information platform

• Improves health literacy by providing chronic medical and behavioral health education to patients and families

• Prioritizes patient cases for systematic population and caseload review by gathering input from ECM team members

• Facilitates communication between patients and providers by identifying health and wellness goals to incorporates into health action and shared care plans

• Coordinates physical care management and care coordination relationships with external healthcare providers

• Receives, identifies, and follows-up with treatment and medication alerts

• Consults with the ECM team members about clinical concerns and questions

• Ensures smooth transitions of care by coordinating patient admission and discharges with hospitals

• Conducts medication reconciliations with input from the providers

• Tracks and assures required assessments and screenings are performed, including comprehensive health assessments and shared care plans

• Reviews adult comprehensive health assessments upon completion by other care team members

Quality Management & Record Keeping

• Contributes to the success of the organization by participating in quality improvement activities

• Documents all patient care coordination, education, and other services in the ECW

• Prioritizes activities according to intensity, need, and required follow-up

• Provides accurate and timely reports to management, as needed

Qualifications

Education/Experience

• Bachelor's degree in nursing required; master's degree preferred

• Valid CA Registered Nursing license in good standing required

• Valid BLS certification from approved American Health Association provider required upon hire

• Three years' experience in healthcare required

• Experience with community outreach, behavioral health, working with high-risk and/or pediatric populations is required

• Bilingual (English/Spanish) preferred

• Valid CA Driver's License and proof of auto insurance is required

Additional Qualifications(Knowledge, Skills and Abilities)

• Excellent verbal and written communication skills, including superior composition, typing and proofreading skills

• Ability to work with Microsoft applications, such as Excel and Word

• Ability to interpret a variety of instructions in written, oral, diagram, or schedule form

• ability to interact effectively with clinic personnel, patients, and community-based organizations

• Knowledgeable about and experience social and health issues

• Knowledgeable about and experience with evidenced based communication such as Motivational Interviewing, or similar empathy-based communication strategies (emotional intelligence)

• Excellent interpersonal and conflict resolution skills

• Ability to sufficiently engage patients and providers both on the phone and in person

• Knowledge about sensitivity to multi-cultural community, mental health conditions, and addictive disorders

• Awareness of the impact of unmitigated bias and judgement on health; commitment to addressing both

• Ability to successfully manage multiple tasks simultaneously

• Excellent planning and organizational ability

• Ability to work as part of a team as well as independently

• Ability to work with highly confidential information in a professional and ethical manner

Physical Requirements

• Ability to lift/carry 25 lbs/weight

• Ability to stand for long periods of time

Pay range: $52.44-$64.10 per hour, depending on experience.