Providence St. Joseph Health

Description:

Providence is calling a Complex Care Management RN (Full time/Day shift) at Providence Facey Medical Foundation in Mission Hills, CA.

We are seeking a Complex Care Management RN who will be responsible for managing and coordinating care for high risk patients, special needs population, and dual care patients that are assigned from the primary care physicians, health plans and other providers. Responsibilities includes complex triage, outreach calls, developing individualized care plans, assists in care coordination, coordinate complex placement, transportation, helps with patient appointments, coordinate care directly with PCP/Specialist, assist with referrals, participate in interdisciplinary care team (IDCT) meetings, create referrals to health plan programs related to diagnosis, provide patient education, other resources related to chronic disease care management. Completes High Risk review and Works with Medical Director to determine other appropriate care needs. Serves as an advocate and liaison between patients, their families, and healthcare providers. CCM Nurses will help in coordinating multiple services, such as pain and symptom management, home health, provider home visits, home based palliative or terminal care needs, assistance with daily living, social worker services, behavioral health coordination, transplant coordination, skilled nursing placement from home or a range of other types of support.

In this position you will:

• Perform job functions timely and efficiently

• Deliver upon the service expectations of both our patients and fellow staff members by listening to their needs; engaging in positive interactions; and following through on promises made in a thoughtful, efficient, timely and courteous manner so that their total outcome is better than expected

• Respect the dignity, confidentiality and privacy of patients

• Work in a safe manner, adhering to general safety precautions and standards. Report any unsafe conditions to their supervisor and/or the safety hotline

• Assist in orienting/training new Complex Care Management Nurses in the CCM area

• Will perform outreach calls to members identified for the complex care management programs (i.e. CCM/SNP/Dual)

• Schedule appointments with PCP/Specialists, nurse care managers, mail out materials related to the care management programs (i.e. educational materials, welcome packet, advance directives, Urgent Care Flyer, Red Flag teaching, etc.)

• Work with Supervisor and other staff in related care coordination services to the Accountable Care Organizations line of business

• Work on care coordination services such as Palliative Care review, Advanced Care Planning: Review of Avoidable Emergency Room visits, High Urgent Care, Hospital, ER Utilizers, Skilled Nursing Facility Placement and other coordination services

• Assist Complex Care Coordinator with care coordination; arranging services for members, such has home health, DME, physician appointments, specialist appointments, and transportation information and to community resources

• Follow up with patients to ensure arranged services are receivedAssists patients and care managers on referral authorization requests for High Risk program patients. Coordinating with PCP and Specialist office. Managing CCM work queues.

• Work with all clinical teams as a resource on care coordination of all patients of the practice, this would include the following:

• Serve as a resource to clinical staff and providers to meet quality goals by reaching out to patients

• Maintain strict confidentiality; follow HIPPA regulations

• Treat staff, physicians, NPs/PAs, visitors, patients and families with dignity and respect

• Participate in professional development activities

• Perform other related work as required

• Follow up with patients to ensure arranged services are received

• Involve the patients in activities to improve their health (patient engagement)

• Educate the patient about self-management tasks they can undertake to gain greater control of their health status

• Assist the High Risk team in developing and implementing chronic disease care programs to improve quality of care for high risk members

• Actively manage assigned panel of chronic care patients (high acuity):

• Develop relationship with patient as an integral member of team by phone, portal, etc.

• Provide follow-up contact with patient as indicated to ensure compliance with recommendations – medications, lab/x-ray, specialist visits, PCP visits, dietitians, CDE, etc.

• Anticipate the needs of this patient population, seeing that necessary documentation and pre-visit planning is completed or requested before patient visit

• Collaborate with the patient, physician, and other care team members in assessing the patient’s progress toward individual health care goals

• Communicate barriers to physician when patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointments

• Assist with procurement, and adoption of patient self-management educational resources used by the primary clinical teams

• Manage many aspects of the patient’s care: referrals to specialists, hospitalizations, ER visits, ancillary testing, and other enabling services

• Educate patients how to do self-management tasks and report abnormal findings to their physician team

• Ensure safe and effective care while the patient transitions in the care continuum

• Serve as the bridge between consulting physicians, hospitals, ER and other frequently used healthcare resources and the patient and/or family

• Collaborate with physician, NP/PAs, clinical and non-clinical staff to identify appropriate patients for care transition services

• Help coordinate consult/referral, hospital/ER, and community resource follow-up for the practice

• Coordinate clinical follow-up with patients per protocol when indicated

• Assist with care coordination services such as Palliative Care review, Advanced Care Planning

• Review of Avoidable Emergency Room visits, High Urgent Care, Hospital, ER Utilizers, and Skilled Nursing Facility Placement, Transplants, behavioral health and other coordination services

• Assist with care coordination, arranging services for members, such as home health, DME, physician appointments, specialist appointments and transportation and to community resources

• Provide information and guidance to patients and/or family regarding effective care transitions and enhanced patient-care team communication

• Maintain accurate and timely documentation

• Distribution of work: Daily production will vary from day to day. All assigned work must be completed by the end of business day in order to maintain customer service to High Risk/SNP/Dual patient’s/Social Worker/Skilled Nursing Facility/Palliative/Accountable Care Organization patients and referral turnaround time compliance

• Attend UM/CCM Staff meetings

• Attend CCM team huddles

• Participate in the huddles, phone calls and team meetings as time and physical location allows

• When possible, takes the initiative to offer help to co-workers in overload situations

• Physicians and co-workers are treated courteously

• Complaints are researched and responded to the same day if possible

• Actively participate in all Interdisciplinary Care Team (IDCT) meetings and have an individualized comprehensive plan of care to present to all members of the team, Primary Care Physician and Medical Director

• Attend all webinars, in-services and educational seminars to enhance clinical knowledge and skills and comply with regulatory requirements

• Attend all UM/CCM staff meetings

• Attends all huddles

• Report promptly any suspected or potential violations to laws, regulations, procedures, policies and practices, and cooperates in investigations

• Conduct all transactions in compliance with all company policies, procedures, standards and practices

• Demonstrate knowledge of all applicable compliance and legal requirements of the job based on the scope of practice of the position

• Excellent attendance record

• Wear appropriate clothing for job functions

• Work at maintaining a good rapport and a cooperative working relationship with staff and physician offices

• Represent the organization in a positive and professional manner in the community

• Maintain organizational, employee and patient confidentiality at all times

Qualifications:

Required qualifications:

• Associate's Degree in Nursing

• California RN license

• American Heart Association BLS for Health Care Providers

• 2 years hospital setting in any of the sub specialty areas such as; Medical surgical unit, Emergency Room, Telemetry Unit, Oncology, Intensive Care Unit and/or combined Home Health and/or Case Management experience

• Knowledge of medical practice and care of patients

• Knowledge of examinations, diagnostic and treatment procedures. Knowledge of common safety hazards

• Ability to use good judgment and critical thinking skills; ability to identify and resolve problems

• Ability to apply guidelines and protocols

• Ability to establish and maintain effective working relationships with patients, families, medical staff, and co-workers

• Ability to work independently, while collaborating with other team members and work with a diverse patients/family population

• Ability to self-motivate, prioritizes, and is willing to invest in a change process to improve efficiencies

• Excellent written, verbal and listening communications skills

• Proficient computer skills – data entry, retrieval and report generation

Preferred qualification:

• Bachelor's Degree in Nursing or Health care related field

About the ministry you will serve:

Facey Medical Group is a multi-specialty medical group with over 160 physicians providing care to the growing population in the North & East regions of Los Angeles & Ventura Counties. Twelve medical clinics, including two urgent care centers and dedicated women's centers, are located across the San Fernando, Santa Clarita and Simi Valleys. The group began as a single medical practice over 90 years ago. Facey is now part of Providence Health & Services, an integrated, not-for-profit 5-state network of hospitals, care centers, medical clinics, affiliated services and educational facilities spanning from California to Alaska.

For information on our comprehensive range of benefits, visit:

http://www.providenceiscalling.jobs/rewards-benefits/

Our Mission

As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

About Us

Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

Schedule: Full-time

Shift: Day

Job Category: Case Management

Location: California-Mission Hills

Req ID: 273134