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Care Management RN

Company: Meritage Medical Network
Location: Novato
Posted on: June 20, 2022

Job Description:

General Summary: The Care Management RN (DCE) manages defined populations by using a collaborative process of assessment, planning, implementation, and evaluation, to engage, educate, and promote/influence beneficiary decisions related to achieving and maintaining optimal health status in the Outpatient setting. The Care Management RN (DCE) uses a combination of proactive telephone calls, hospital, MD office, and home visits to beneficiaries who are enrolled in Meritage's medical and wellness programs. This position is responsible for developing and maintaining ongoing supportive relationships with all members of the Care Management Team and beneficiaries. Principal Accountabilities:

  • Reaches out to patients identified as appropriate to provide information and education in order to deepen their understanding of their medical condition and to guide the patient in self-management of the chronic disease.
  • Emphasizes the value of health education and behavior modification.
  • Participates in all aspects of the Care Transitions Program.
  • Actively participates in the Care Team to improve/maintain positive healthcare outcomes and care transitions.
  • Works in collaboration with the individual patient and his/her attending physician.
  • Supports the Primary Care Physicians and their office staff.
  • Applies the standard elements of assessment, planning, implementation, coordination, monitoring, and evaluation and will use state-of-art information tools.
  • Is highly organized, effective at managing her/his time, and is skilled in the use of computers and multiple software systems.
  • Remains objective in relationships with patients, families, and physicians and promotes a team approach by encouraging communication among all members of the care team.
  • Coordinates care among multiple treating physicians including specialists, primary care, hospitalists, and behavioral health care, as necessary.
  • Performs other clinical and related administrative duties as assigned to support the organization's operational needs. Qualifications:
    • Current California RN License with no restrictions and a minimum of 5 years clinical experience, previous case/care management experience is preferred.
    • BSN preferred.
    • Coleman model trained is a plus.
    • Direct Contracting Entity (DCE) and Accountable Care Organization (ACO) experience desired. Requirements:
      • Familiarity with data collection and methods of analyzing and reporting data, metrics, and related information pertaining to clinical health programs.
      • Professional written and verbal communication skills.
      • Ability to function effectively in a team with patients, families, physicians, MD office, and other Meritage departments and staff.
      • Treats others in a respectful, kind, and patient manner.
      • Demonstrates sound clinical judgment and critical thinking in accordance with the California Nurse Practice Act.
      • Self-motivated, able to ask for assistance, and adapts easily to change.
      • Has a strong sense of accountability for work performed and in meeting deadlines.
      • Knowledgeable about the available health care and community resources for the populations managed.
      • Understanding of family dynamics and the influence of cultural and spiritual values in health care.
      • Current valid driver's license and reliable transportation with the required level of automobile liability insurance coverage

Keywords: Meritage Medical Network, Novato , Care Management RN, Healthcare , Novato, California

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