Full time office position-Case management practice that was founded by Registered Nurses to provide care and care management to high risk members.
This is a great opportunity to get your foot in the healthcare field specializing in Case Management which is widely needed.
Duties and Responsibilities:
1. Engages patients and offers and/or facilitates care management services where the patient lives, seeks care, or finds most easily accessible.
2. Conducts comprehensive risk assessments and develops patient-centered Care Plans that includes goals based on the patients’ physical and psychosocial health needs and considers their personal preferences.
3. Oversees effective implementation of Care Plan, ensuring initial plan is drafted with 50 days from the patient’s enrollment and that it is updated as necessary, but no less than one per quarter, thereafter.
4. Educates patients on self-management skills and/or recruits support from a caregiver/family member to support the accomplishment of the Care Plan.
5. Supports health behavior change utilizing motivational interviewing and trauma informed care practices.
6. Monitors treatment adherence.
7. Regularly initiates or participates in case conferences with clinical providers.
8. Connects patient to social services, including housing, transportation, etc., as needed to achieve patient’s goals and well-managed care.
9. Coordinates with hospital staff on discharge plan and with other transitional care as feasible.
10. Accompanies patient to office visits, as needed and according to health plan guidelines.
11. Maintains a regular contact schedule with enrolled patients that includes at least one in-person encounter per month.
12. Document care management encounters in the Electronic Health Record (EHR) with the appropriate billing codes and internal tracking logs.
13. Perform other duties as assigned.
14. Open to seeing patients in person or their location of preference.
Qualifications:
High School Diploma or equivalent
Computer literate i.e., Microsoft products
Bilingual: Spanish (required)
Great communication skills
Able to work with others in a team oriented environment
