St. Joseph Health / Covenant Health Care Manager RN - Utilization in Anaheim, California
We are looking for a Care Manager RN with HSS IP Utilization at St. Joseph Heritage Healthcare.
Location: Anaheim, California
Work Schedule: Part-Time - 40 Biweekly Hours
Shift: 8 Hour Day Shift
Care Management is a collaborative practice model including the patients, nurses, social workers, physicians, other practitioners, caregivers, and the community. The care management process encompasses excellent communication, both verbal and written, and facilitates care along a continuum through effective resource coordination.
The goal of the Care Manager is to advocate for and assist the patient in the achievement of optimal health, access to care, and appropriately utilizing resources. The Care Manager utilizes the following processes to meet the patient's individual healthcare needs: assessment, planning, implementation, coordination, monitoring, and evaluation of the plan of care.
Assessment: The Care Manager will collect in-depth information about a persons’ situation and functional status to identify individual needs in order to develop a comprehensive plan of care that will address the patient’s needs. The Care Manager will identify both present and possible future needs of the patient and family, which may affect the plan of care and the patient’s well-being. This assessment will include age-specific physical, psychosocial, environmental, financial, and health status expectations.
Planning: The Care Manager will identify specific objectives, goals, and actions, as identified during the assessment process. Acting as a patient advocate the Care Manager will collaborate with the physician, the patient & family, and members of the healthcare team, to formulate a shared plan of care. Goals and time frames for goals, appropriate to the patient, will be set.
Implementation: Executes specific interventions that will lead to accomplishing the goals and timeframes of the shared plan of care. Works effectively with the healthcare team to determine the necessary steps to achieve the plan of care. Problem-solving techniques will be applied to the implementation process. The Care Manager will utilize knowledge of alternative funding sources, benefit plans, and contractual information to promote appropriate quality, cost-effective care for members throughout the healthcare continuum.
Coordination: Organizes, coordinates, provides, modifies or obtains appropriate authorizations, utilizing appropriate utilization review and evidence of coverage guidelines, to accomplish the patient’s goals. Initiates and communicates with the patient and family, physicians, healthcare members, community, and payor representatives. Facilitates continuity of care throughout all access points involving Health plans, discharge planners, physicians, and other appropriate staff.
Monitoring: Obtains sufficient information from all relevant resources in order to determine the effectiveness of the plan of care, and services provided. Manages a caseload of high risk, complex needs or catastrophic patients.
Evaluation: At appropriate and repeated intervals, assesses, and reassesses the patients’ progress. If progress is static or regressive, determines the reason, and encourages the appropriate interventions to obtain optimal outcomes. The Care Manager will modify the plan of care, as necessary, in coordination with the healthcare team, family members, and providers.
Communication: Communicates both verbally and electronically with the patient and the healthcare team. Appropriately documents the plan of care, outcomes, statistical reporting, logs, and files abiding to departmental, legal, and regulatory requirements.
Basic computer skills including Windows, Microsoft Word, internet navigation, and an e-mail system.
Knowledge of managed care principles, utilization management, case management, and healthcare provided throughout the continuum.
Knowledge of physical and psychological characteristics of disease processes recognizes potential clinical problems and recommends intervention in a preventative, pro-active way.
Excellent interpersonal, verbal, and written communication skills.
Ability to problem-solve.
Ability to access and evaluate community resources to meet patient’s needs.
Ability to handle multiple tasks at a time and remain organized.
Ability to work autonomously but demonstrates the ability to work collaboratively on a team.
Ability to work in an ambiguous environment; work effectively under pressure due to changes in priorities.
Excellent computer and IT system knowledge.
Possesses the knowledge and skills necessary to communicate with third-party payers.
Establishes and maintains a good rapport with physicians and interacts well with all internal and external customers in a professional and courteous manner.
Proficiency in Milliman Care Guidelines preferred.
- Graduate of an accredited school of nursing.
- Three (3) years of Clinical experience in an HMO, medical group, affiliated model, hospital or medical office/clinic setting.
License / Certifications:
- Active and unrestricted California Registered Nurse license.
Preferred Position Qualifications:
- Bachelor's Degree in Nursing Or Master's Degree in a related field.
- Three (3) years of experience in utilization management or case management.
License / Certifications:
Certification in Case Management (CCM, ACM)
Specialty Certification in Oncology, Rehab, Pediatrics, Transplant or Wound Care
Mission Heritage Medical Group is one of California's most respected medical groups. With over 3,000 employees and 75 locations throughout California, including, Northern California, Orange County, High Desert and Los Angeles County, Mission Heritage Medical Group has been continually recognized as a leader in quality, customer service and information technology. This kind of success is the result of team work, a commitment to excellence and a strong adherence to the organization's mission, vision and values.Mission Heritage Medical Group provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Mission Heritage Medical Group complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
Company: Heritage Healthcare
St. Joseph Health / Covenant Health
- St. Joseph Health / Covenant Health Jobs