Nurse,(RN)Out-Patient Case Mgr

The RN Case Manager provides daily care coordination, case management, coaching, consultation and intervention to patients with one or more chronic diseases. The RN Case Manager is responsible for identifying said population via provider/clinic referral, utilization management referral, disease registry reporting mechanisms and patient self-referral. This position will also provide case management to patients who are admitted to the hospital and those patients who may need to be enrolled in ambulatory case management. Works as part of an interdisciplinary care team coordinating social work and mental health counseling, psycho-social support services, in-home support, legal services, skilled nursing, home health, etc. The RN Case Manager effectively collaborates with members of the interdisciplinary care team and with the physician in the clinic. The RN Case Manager performs telephonic face to face assessments on assigned patients. The RN Case Manager serves as the leader of a cohort of LVN Case Managers, Case Manager Coordinators, and Social Workers providing Case Management to a specified population of patients. RN Case manager provides support and guidance to said cohort.

1. Follows established policies, procedures, workflows and desktop procedure of the department.
2. Responsible for managing members through implementation of the CM process.
3. Effectively and efficiently manages patients throughout the continuum of care and makes appropriate quality and quantity calls to patients.
4. Works collaboratively with Hospitalists, hospital partners, and care teams to provide holistic patient care that is focused on high quality in a cost effective way.
5. Develops a working relationship with the hospital case managers, health plan, clinics, hospitalists and other governing entities.
6. Identifies and enrolls patients into a case management program providing intensive service.
7. Conducts intakes and comprehensive assessments per health plan and department’s policy.
8. Identifies needs and develops individualized care service plans on behalf of clients; an active participant in case conferences; attends divisional coordinators meetings and regular staff meetings; re-evaluates patients as needed; monitors the services delivered by team participants.
9. Attends Joint Operation Meetings (JOM) meetings and various community meetings as needed.
10. Monitor ongoing services and their cost effectiveness; recommending changes to the plan as needed using clinical evidence-based criteria – Milliman, Interqual, CMS, National Recognized American Academy of Specific Specialty.
11. Assist in performing and documenting patient outreach telephonic and or face to face to reduce the likelihood of readmissions and responsibilities including but not limited to PCP appointments, ensure DME Home Health is ordered, referring for social barriers for referrals to social workers.
12. Perform and document patient telephonic and/or person-to-person risk assessments as needed.
13. Able to provide assistance to the Regional LVN Case manager and coordinator assigned to the care coordination team.
14. Participates in process improvement workgroups as assigned.
15. Performs other related duties as assigned.

1. Graduation from an accredited nursing program.
2. Current valid License as a Registered Nurse through the California Board of Registered Nursing; Bachelor’s degree in social work, nursing, or another health or human services field with the appropriate licensure preferred.
3. Experience in and willingness to be part of multi-disciplinary team.
4. Experience with physically or mentally impaired adults and/or geriatric population.
5. Three years RN experience in public health nursing, acute care, case management and/or home health care required; minimum of 2 years of managed care experience in case management with focus in inpatient and/or outpatient ambulatory care preferred.
6. Bilingual in English and Spanish preferred.