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Case Management Nurse

Company: Meritage Medical Network
Location: Novato
Posted on: November 19, 2022

Job Description:

*Position Summary: *The outpatient Care Management Nurse is the key contact with the patient and providers. They are responsible for providing comprehensive assessments and developing, coordinating, and implementing the plan of care with other team members on those patients assigned. Maintain extensive knowledge regarding the current standards of care and care management processes for Asthma, COPD, Diabetes,Heart Failure, and/or other program-specified condition(s). Involved in two main programs at Meritage:Care Transitions and Complex Care Management.*Principal Responsibilities: **Care Transitions Program** Provide post-hospital discharge support to all Meritage members who qualify for CareTransitions (depending on health plan) - based on Coleman Model (30-day program).* Patients will receive either telephonic or face-to-face care transitions support.* Use criteria such as the LACE tool to identify high risk patients.* Goals and objectives:* Reduce preventable readmissions.* Increase the number of patients that are seen by an MD within 7-10 days of discharge.* Provide medication reconciliation and assist in identifying and correcting medication discrepancies.* Provide teaching regarding disease process, medications, community resources.* Educate members on seeking the appropriate level of care.* Reduce utilization costs by evaluating users with high outpatient costs.* Refer patients as appropriate to behavioral health staff.* Create personalized care plan for patient.*Complex Care Management** CCM services to those patients identified as high-risk and will be referred into the program.* Patients referred into the program will receive telephonic support for up to 90 days, as well as a home visit from the RN Care Manager (RN CM).* Identify patient-centered goals and create personalized Plan of Care.* Work with patient to achieve goals of care.* Educate patient regarding disease processes, medications, community resources.* Provide medication reconciliation as appropriate.* Assist members with seeking appropriate level of care.* Provide referral to Behavioral Health Care Management if appropriate.* Work with Utilization Review for authorizations/provider referrals as appropriate.* Work with quality department to improve quality scores.* Patients who receive a home visit will also receive three follow up phone calls to address any ongoing needs, questions, or concerns.* RN CM may provide the following via telephone or home visit (if deemed clinically appropriate):* Assessment of patient health status.* Identify patient centered goals and create plan of care.* Educate patient regarding disease processes; signs and symptoms, when to notify MD.* Interdisciplinary collaboration with MDs, therapists, home health agencies, family, etc.* Discussion of preventative health measures.* Medication reconciliation/discrepancies.* Teaching of disease process, signs, and symptoms to be concerned about and when to call the doctor.* How to seek the appropriate level of care.* Referral to community resources/caregivers, etc. as appropriate.* Home safety evaluation/falls risk assessment.* Review of life planning/advanced care directions.* Review of hospital discharge instructions if indicated.* Work with UM for proper authorizations/providers if indicated.* Provide ongoing support for patient to achieve goals.* CCM patients are brought into weekly rounds with medical director.* Consistently demonstrate behaviors, conduct and communications that support Meritage'sPractices and Values of *Accountability, Diversity, Integrity* and *Respect* for others, and will seek to influence these behaviors in others.* Continuously endeavors to "raise the bar" of performance and teamwork through a focus on*Innovation, Collaboration*, *Equality* and *Compassion.**SNF 3-day Waiver Program** Participate in the 3-day waiver program.* Point-person for hospitals, Skilled Nursing Facilities, primary care provider.* Care transitions/CCM for fee for service Medicare/Medicare Advantage beneficiaries who qualify for the 3-day SNF waiver (see above for duties for each service).*Qualifications, Requirements and Skills: ** RN with current, unrestricted license in the state of California.* 2+ years' experience in inpatient or outpatient nursing. Case Management experience highly preferred.* Bachelor's or Master's degree in nursing preferred.* Able to work with different healthcare settings: Inpatient vs. Outpatient.* Knowledge of CM regulations that fall under CMS, NCQA, DMHC and other applicable state and accreditation standards.* Demonstration of sound clinical judgment and critical thinking in accordance with the California Nurse Practice Act.* Commitment to service excellence and patient satisfaction.* Proficiency in office-based software applications, including Word, Excel, Outlook, Teams and working knowledge of other healthcare charting software required.* Ability to develop and maintain effective working relationships with other teammates, patients, and the public.* Ability to multi-task in a fast-paced clinical setting.* Excellent verbal, written and interpersonal communication skills.* Ability to collaborate and build strong client relationships across all levels of the organization including clinical staff, physicians, and administrative leadership to meet deliverables.* Ability to obtain reliable transportation to-and-from patient homes/facilities, when applicable.* Aptitude for coaching, training, and developing new teammates.Job Type: Full-timeBenefits:* 401(k)* Dental insurance* Health insurance* Vision insuranceMedical specialties:* Home HealthStandard shift:* Day shiftSupplemental schedule:* HolidaysWeekly schedule:* Monday to FridayEducation:* Bachelor's (Required)Experience:* Nursing: 2 years (Required)License/Certification:* RN (Required)Work Location: Hybrid remote in Novato, CA 94949

Keywords: Meritage Medical Network, Novato , Case Management Nurse, Executive , Novato, California

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