Dignity Health Medical Foundation, established in 1993, is a California nonprofit public benefit corporation with care centers throughout California. Dignity Health Medical Foundation is an affiliate of Dignity Health - one of the largest health systems in the nation - with hospitals and care centers in California, Arizona and Nevada. Today, Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers, we provide increasing support and investment in the latest technologies, finest physicians and state-of-the-art medical facilities. We strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled, qualities that are vital to maintaining excellence in care and service.
The RN Care Coordinator is an integral part of Dignity Health Care Coordination team. The Care Coordination program improves the quality of care and clinical outcomes for members with complex care needs by coordinating care within the health care delivery system using a collaborative partnership approach. The RN Care Coordinator coordinates care and collaborates with multiple disciplinary team members across the continuum of care. Through assessments to determine unmet needs and development of the individual's care plan, the RN Care Coordinator evaluates and identifies knowledge gaps of disease process and treatments, determines appropriate resources or services required to meet an individual's health needs, provides education/coaching on disease self management for health promotion and maintenance, monitors patient's progress, promotes quality cost effective outcomes with the goal of improved care coordination amongst providers and increased involvement of the individual, family, and/or caregiver in the decision making process to reduce hospitalizations, readmissions and ER visits. This position will involve telephonic case management and direct patient contact through follow up at clinic appointments and/or home visits as needed. Travel may be required with telecommuting option.
Responsibilities may include:
- Concurrently reviews patient’s records to collect data to carefully understand the needs of the patient by scrutinizing their background history, understanding their current needs, and arranging for their wellbeing.
- Coordinates with other disciplines to facilitate the patient’s individual needs. Makes plans to resolve unexpected care requirements. Anticipates and identifies variances in the care process related to those identified needs.
- Assists in development, implementation and revision of individual care plans; assures that services provided are specified in the Care Plan and monitors progress toward goals, including documentation of daily improvement in patient’s condition or otherwise notes lack of improvement for reassessment of appropriateness of care plan.
- When barriers are identified, assists the patient and the family/caregiver in developing, documenting and implementing appropriate care plans to access agencies, resources and care providers.
- Teach, coach and educate the patient, family and/or caregiver about their disease process to recognize signs and symptoms of worsening disease and how to take appropriate measures.
- Documents patient, family or caregiver's knowledge regarding medical condition(s), and indicates when condition is worsening and develop a plan for how to respond.
- Supports the medical management plan provided by the patient's primary and specialty providers and educates patient on established treatment options.
- Promotes patient self management, problem solving and empowers patient, family and/or caregiver to achieve maximum levels of wellness and independence.
- Assists patient with navigating the healthcare system to minimize fragmentation in services, obtain timely care and appropriate access to providers, services and necessary procedures.
- Monitors patient's compliance with scheduling and keeping PCP and specialist appointments identifying patterns of non adherence and coordinates scheduling of needed patient appointments.
- Contacts patient telephonically, meets patient at clinic appointments or other settings (e.g. SNF, hospital) or conducts home visits as needed to assist with care coordination.
- Identify and assist patient with obtaining community resources and services to address the established goals or desired outcomes.
- Communicates with the nursing home physicians, regularly, to evaluate the status of each patient. Collaborates with other team members to ensure appropriate interventions are implemented. These communications will be needed as frequently as is needed to ensure care is appropriate according to patient status.
- Coordinates with other disciplines to facilitate the patient receiving the required care at the expected time including plan of care to reduce incidence or re-admission to acute care setting, including physical, occupational and rehabilitative therapy.
- Coordinates transfers to a lower level of care, home health referrals, and durable medical equipment delivery to facilitate discharge from skilled nursing facility.
- Coordinates with Home Health to identify continued care needs and establish continuity of care coordination upon Home Health discharge.
- Measures effectiveness and outcomes of the care plan and collaborates with the health care team for quality improvement.
- Other duties as assigned.
- Two (2) years clinical experience as a RN in acute, ambulatory care, home health, skilled nursing facility, medical group or health plan setting required. A Masters Degree in nursing with a concentration in Case Management can serve as a substitute for the experience requirement
- Current CA Registered Nurse (R.N.) license
- Excellent customer service and presentation skills are a must
- Strong interpersonal and written communication skills are essential Demonstrated ability to apply analytical and problem solving skills
- Ability to demonstrate leadership skills to delegate and provide direction/guidance to multidisciplinary team
- Demonstrated ability to manage multiple tasks or projects effectively
- Ability to work independently as needed with a high degree of detail orientation
- Ability to work efficiently in a fast-paced environment with changing priorities
- Knowledge of regulatory and accreditation standards (URAC, NCQA) and complex case management (CMSA)
- Knowledge of community resources
- Knowledge of capitation/HMO, insurance payers and government healthcare plans and audits
- Prior Care Coordination experience in a clinical or insurance setting is required
- If operational conditions permit, training a candidate without the required experience may be considered
- BSN degree or experience equivalent preferred. CM certification preferred
Keywords: care coordination, case management, home health, public health, community, RN, registered nurse
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