Desert Sage Health Centers is currently recruiting an, experienced, energetic full time RN Chronic Care Case Manager to be part of our team. The Case Manager is responsible for planning, facilitating, improving, and coordinating comprehensive services across the continuum of care. Part-time telecommute options will be considered for the right candidate after relationships with patients and care teams have been established
Purpose of Position: The RN Case Manager develops DSHC's case management program, and actively works with patients and staff to improve patient outcomes, close care gaps, and ensure comprehensive, life-saving care is received by DSHC's patients. The Case Manager coaches the staff on the RN-patient-physician collaborative process of assessment, planning, implementation, coordination, monitoring, and evaluation to address patients holistically. This plan includes ongoing screening of the member for changes in health status and coaching for improved self-management. Overall, the RN Case Manager serves as a clinical champion in the health center for improving patient care and safety, improving quality measures, enhancing the integration of care team operations, and facilitating clinical-quality improvement efforts.
- Develop and document systems for risk stratification, registry creation and maintenance, closed-loop care (test/lab tracking, referral tracking, etc.), case management documentation, and standard workflows.
- Train providers and other DSHC staff on risk stratification and care-management scope and workflows.
- Assist in implementation, roll-out, ongoing maintenance, and ongoing training of clinical staff DSHC's population health management tool; assist in the development of workflows that tie together clinical practice and population health data.
- Develop, monitor, and report metrics throughout the health center to identify patient progress and overall success of Care Management program.
- Maximize team-based care by developing strong working relationships with specialty providers and the DSHC care teams.
- Serves as a leader in the health center for improving care, quality measures, enhancing integration of care team operations, and facilitating quality improvement efforts, as demonstrated by leading at least one documented QI project annually
- Supervise care coordinators, including scheduling, delegation of work, team assignments, performance management, coaching, teaching, professional development/training plans, and development of basic clinical and care-management knowledge to support them in their roles.
- Be available to Care Coordinators via in-person, phone, or electronic communications, including responding to messages as soon as possible. Maintain frequent communication with Care Coordinators.
- Delegate appropriate tasks to care coordinators for patient outreach and self-management support, scheduling follow-up and closure of care gaps, connecting patients with community resources, etc.
- Work with care teams and leadership to develop a prioritization list for building and managing case management panels.
- Provide chronic care management to highest risk population, including oversight of patients on Controlled Substance Agreements.
- Facilitates patient medication management based upon standing orders and protocols; includes conducting reconciliation for polypharmacy patients to ensure medication safety and patient understanding of medication use
- Facilitates health and disease patient education.
- Supports patient self-management of disease and behavior modification interventions.
- Documents chronic care management activities in the EMR to ensure maximum revenue capture; teaches care coordinators and other staff how to document time spent on CCM activities for Medicare/dual eligible patients.
- Establish a mechanism to reliably identify and track patients discharged from inpatient care; ensure patients discharged from the hospital are seen within 7-14 days of discharge.
- Complete post-discharge calls to patients within 72 hours of discharge according to standard scripting (medication review, upcoming appointments, plan of care as outlined by hospital, etc.)
- Build a strong relationship with the hospital, and serve as the patient care liaison to ensure DSHC is able to receive notification and discharge information from the hospital(s) when patients are discharged and/or need follow-up appointments, leveraging health information exchange whenever possible
- Responsible for working preventive care gap lists (with assistance from care coordinators), to ensure high-risk patients receive appropriate screenings and services
- Coordinate services with other service providers, inside and outside of DSHC.
- Promotes clear communication among the care team by ensuring awareness regarding patient care plans.
- Ensure patients with substance abuse and alcohol abuse disorders are connected with appropriate support services.
- Must hold current RN License in Idaho
- BSN degree required
- Must hold current CPR card (healthcare provider)
- 3-5 years of direct experience providing case management to diverse patient populations
- Demonstrated understanding of best practices in chronic disease case management and population health.
- Demonstrated ability to aggregate, analyze, and act upon clinical data
- Demonstrated experience with running quality improvement projects and process improvements preferred
- Bilingual English/Spanish Preferred
If you are self-motivated, compassionate, leadership-oriented, and ready to give back to your community, we are looking for you.
Job Type: Full-time
To apply for this position visit the Desert Sage Health Center Careers Page for application and instructions.