NURSE CASE MANAGER I P

Nurse Case Managers are licensed nursing professionals responsible for coordinating continuum of care and discharge planning activities, developing individualized person-centered care plans and goals, and facilitating case conferences among all service providers for a caseload of assigned patients.

Nurse Case Managers act as consultant to the clinical team, service lines, and other departments regarding patient assessment and patient care, and participate in program development and quality improvement initiatives in their role, by applying guidelines and collaborating with multidisciplinary teams, Case Managers influence and direct the delivery and quality of patient care.  The objectives are facilitation of timely discharges, prompt and efficient use of resources, achievement of expected outcomes, collaborative practice, coordination of care across the continuum, and performance/quality improvement activities that lead to optimal patient outcomes.

Nurse Case Managers differ from other roles in professional nursing/health care practice in that they do not provide direct medical care to patients; rather, a Nurse Case Manager will be assigned to specific patients to ensure that the medical services and treatments are accomplished in the most financially and clinically efficient manner.

• Apply professional clinical skills and expertise in the assessment, planning, implementation, and coordination of necessary healthcare services.
• Develop and manage individualized care plans to ensure consistent, timely, and appropriate care is provided in a patient-focused manner; collect data, assess needs, identify problems and options, set plans and goals, and monitor and evaluate progress.
• Provide an interdisciplinary process in which healthcare team members collaborate with patients and their families to support quality care and to ensure that patient's care is continuous and integrated among all service providers.
• Provide disease management to patients who have certain medical conditions such as end stage renal disease, cancer, and palliative care.
• Manage patients in various levels of case management programs such as Transition of Care, Chronic Care Management, Enhanced Care Management, Community Support, and Complex Case Management. 
• Facilitate timely implementation of hospital discharge plans in collaboration with other interdisciplinary team members; arrange follow-up care as appropriate.
• Perform home visits to patients meeting transition of care or complex case management criteria; perform medication reconciliation within the nursing scope of practice. Accompany patients to medical visits as needed. Meet patients at their home, public areas, or wherever they reside to facilitate enhanced care coordination services.
• Collaborate with MSO Utilization Management team and PCPs to ensure resource utilization is appropriate; plan and implement strategies to reduce resource consumption and achieve positive patient outcomes.
• Identify community resources and assist patients in applying for the needed services.
• Participate in the development of policies and procedures to meet program requirements; participate in internal and external meetings and designated committees.
• Make complex clinical decisions regarding medical care; involve Medical Directors and providers to solve complex issues.
• Utilize multiple systems to maintain documentation of case management activities; collect, analyze and report on data for utilization, quality improvement, compliance, and other areas as assigned.
• Conduct comprehensive Annual Wellness Visit assessments and summarize findings for PCP to review; evaluate patients for eligibility for case management programs.
• Assist in training new Nurse Case Managers and Care Coordinators in the Case Management team to guide them in accurately completing their work and to ensure adequate understanding of the NEMS CC/CM program.
• Perform other job duties as assigned by manager/supervisor.

• Bachelor’s degree required.
• Valid California Registered Nurse license.
• Current Basic Life Support certification required.
• Valid Driver License and ability to maintain good driving record.
• Demonstrate willingness to make decisions within RN's clinical scope of practice; exhibit sound, accurate, and ethical judgment.
• Ability to engage and work collaboratively with others, including patients, patients’ families, clinical team members, clinical supervisors, and community resources.
• Ability to provide detailed, concise notes/documentation of work within workflow turn-around timelines.
• Basic medical knowledge, including the ability to observe safety and security procedures, and recognize trauma symptoms and behaviors.
• Good communication and interpersonal skills; ability to work with people from
• diverse backgrounds and experiences.
• Able to spend 40-60 minutes at a time with patients in the community, including at clinics, specialist offices, hospitals, community-based organizations, or patient's home which may be in understaffed/remote areas, in the presence of pets or family members that are tobacco users.
• Time management and prioritization skills are vital.

• Must be able to fluently speak, read and write English.
• Fluency in Chinese (Cantonese and Mandarin) required.
• Fluency in other languages is an asset.

• This is an FLSA Exempt position.
• This is not an OSHA high-risk position.