The selected RN or NP Case Manager will provide complex care management in collaboration with health (insurance) plan medical management for patients who agree to Sansum Clinic’s ACO (Accountable Care Organization) engagement letter, of ongoing outreach and care navigation as well as:
> Serve as a consistent care navigator throughout the continuum of care, for the engaged ACO [Accountable Care Organization] patient with multiple, ongoing medical and social concerns.
> Serve as a liaison between the patient, Primary Care Physician, and the various healthcare providers and departments/facilities required for proper diagnosis, treatment and management of the complex clinical conditions.
> Offer care transition support and ongoing communication with PCP, through regular communication and/or case conferences for ongoing care coordination of the PCP’s patients.
> Focus on achieving improved patient outcomes by monitoring and assisting with navigating the healthcare resources available for their complex conditions.
Summary of Essential Duties and Responsibilities (include, but are not limited to):
> Analyze and evaluate health plan data and medical record data of the engaged ACO patient to determine most appropriate outreach (e.g., phone outreach, face to face appointment during a primary care physician visit, home visit) and develop a care plan for that patient.
> Promote a collaborative relationship with the Sansum medical community, especially Hospitalists, Skill Nursing Facility (SNF) providers, primary care providers and all other members of the health care team, including ancillary services such as pharmacy, diabetic educators, nutritionists, social workers, ACC Clinic, oncology navigators, health educations, and community resources etc. to develop appropriate care management plan for assisting and directing the care.
> Promote collaborative relationship with other health care entities in the community who will potentially assist in the ongoing management of the chronically ill patient (e.g., Home Health, Hospice, Palliative Care, Community resources etc).
> Assist in the navigation of local healthcare services throughout the continuum of care decreasing the fragmentation of care and acting as a patient advocate and liaison for all of the patient’s healthcare needs.
> For hospitalized patient: monitor and assist in the coordination of a comprehensive plan of care within health plan benefits and health plans medical management authorizations and collaborative discharge plan with patient’s healthcare team, including post hospital follow up. May include face to face visit with the patient to go over new medications and other potential concerns post hospitalization.
> Educate patients and family to increase understanding of disease, treatment options and care plans and assess and connect patient and families to appropriate resources and support services through regular case conferences or other communication.
> Assist in the development of appropriate, regular re-assessment of engaged patients on an ongoing, regular basis depending on complex needs and patient’s ability to improve healthcare outcomes.
> Prepare and maintain patient tracking logs for members served by the Chronic Care Navigator program. Track and document outreach activities (phone encounters) and face to face visits in the Wave.
> Participate in Case conference with Hospitalists, specialists and/or PCP when appropriate.
> Coordinate with health plan contracted vendors, hospital Case Managers, and providers.
> Coordinate with MCR processes developed for Oncology Drugs, High Cost Injectables and other referral/authorizations for internal services that health plan must authorize.
> Refer any issues on complex cases needing intervention due to healthcare team to Assistant Medical Director for intervention
> Facilitate quality of care and service by referring any potential quality issue To Sansum quality management department, who in turn reports to pts health plan.
> Identify under/over utilization issues and refer to Assistant Medical Director.
> Maintain strictest confidentiality in accordance with Sansum Clinic policy.
40 Hours Per Week
> Must posses a broad knowledge of general medical conditions and have excellent interpersonal and organizational skills as well as the ability to prioritize and work independently.
> Must be computer literate and have the ability to communicate effectively by phone, written word or face-to-face.
> The ability to perform each essential duty independently is a must.
> Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.
> Graduate of an accredited school of nursing.
> Current California RN license.
> Experience working in a Health Insurance Plan
> Five (5) years of Case Management experience.
> A minimum of two (2) years experience in ambulatory, acute care nursing, with a thorough familiarity of health plan, managed care, and customer service.
> Certification in Case Management (CCM)
> Prior experience at a Managed Care Organization (Health Plan, IPA, MSO, TPA, etc).
Comprehensive benefits package offered to all full-time employees.