Works collaboratively with an assigned panel of physicians to manage the patient's specialized needs. The managing team does differ according to the chronic disease. Duties include assessment to identify member needs and development of specific care management plan to address needs. In conjunction with the Physician, implements care/treatment plan by coordinating access to health services across multiple providers/disciplines, monitors care, makes determination to arrange transportation and transfer patient if indicated, identifies cost-effective measures, makes recommendations for alternative levels of care and utilization of resources, promotes self-care management and ensures paper work is completed. Is an indirect caregiver. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team.
Essential Functions: - Evaluates and identifies members' needs. - Interfaces with Primary Care Physicians, Specialists and various disciplines on the development of case management plans/programs. - Monitors and evaluates the effectiveness of the case management plans and modifies as necessary. - Coordinates the interdisciplinary approach to providing continuity of care, including utilization management, transfer coordination, discharge planning and obtaining all authorizations/approvals/transfers as needed for outside services for patients/families. - Acts as a clinical liaison, per their specialty, with outside agencies such as County CCS, non-plan facilities, outside providers, employers and/or workers' compensation carriers and third party administrators. - Prepares reports, communicates program changes to appropriate staff and develops protocols in accordance with state regulations. - Acts as a patient advocate and educator to assure that the patient has the knowledge to care for his/her condition and patient is educated and empowered to be responsible for participating in the plan of care. - Develops individualized patient/family education plan focused on self-management, delivers patient/family education specific to a disease state. - Develops and updates training and educational materials and presents to appropriate staff, members and families. - Facilitates patients' return to normal daily activities by teaching and making appropriate referrals for outside services/continued care. - Consults with internal and external physicians, health care providers, discharge planners, and outside agencies regarding continued care/treatment or hospitalization or referral to support services or placement. - May need to facilitate transportation and housing arrangements for patient. - Coordinates transmission of clinical and benefit treatment to patients, families and outside agencies. - Participates in data collection and analysis of clinical outcomes of care and customer satisfaction standards. - Participates in the formulation and implementation/monitoring of action strategies and outcomes of care or customer service. - Ensures that accurate records are maintained of the care associated with each patient. - Interprets regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff, and contract providers and outside agencies.
Basic Qualifications: Experience - Minimum two (2) years clinical experience as an RN in an acute care or ambulatory care setting required. - Cancer Program:Two (2) years clinical experience in Oncology. - For positions in OB/Gyn:Two (2) years recent (within the past three (3) years) clinical experience in Maternal Child Health, FCC, Ob/Gyn or Women's Health in acute care or ambulatory care. - For positions in Neonatal Intensive Care Unit:Two (2) years clinical experience in a Level III NICU. - For positions in High Risk Infant Program:Two (2) years experience in a Regional or Community NICU; one (1) year of which should be in an HRIF program or as a discharge planner for an NICU and/or in a community-based Medically Vulnerable Infant Program. - This experience may have been at a comparable out-of-state facility. - Total Joint Replacement Travel Surgery Program (OC):One (1) year clinical experience in Orthopedics. Education - Bachelor's degree or equivalent four (4) years of experience required. - For positions in High Risk Infant Program:bachelor's degree in nursing or related field required. Licenses, Certifications, Registrations - Current California RN license required. - AHA BLS. - Cancer Program: OCN required within one (1) year of hire. - High Risk Infant Program: Meet requirements to be a CCS paneled provider. - Regional Genetic Screening Program: BLS is not required
Additional Requirements: - Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques and methods of utilization review/management, care coordination, transfer coordination, discharge planning or case management. - Working knowledge of regulatory requirements and accreditation standards (TJC, Medicare, Medi-Cal, etc.). - Demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking and problem-solving skills required. - Computer literacy skills required.
- OB/Gyn: Demonstrated knowledge of maternal/fetal medicine, including high risk pregnancies. - High Risk Infant Program:Case management of patients in a High Risk Infant Program. - High Risk Infant Program: Ability to manage annual Synagis Clinic for at-risk population.
Preferred Qualifications: - Cancer Program: Two (2) years experience in Ambulatory Oncology preferred. - Total Joint Replacement Travel Surgery Program (OC): One (1) year experience in Total Joint Replacement preferred.
- Bachelor's degree in nursing or healthcare related field preferred. - For positions in High Risk Infant Program: Master's degree and PHN preferred.
- Case Management Certification or certification in the area of specialty preferred.