Care Manager, RN (On-site, hybrid, remote)
Welcome to Montage Health’s application process!
- CHOMP has been voted the Best Place to Work in Monterey County for 10 straight years
- Excellent Pay and Generous Benefits including a Pension and Continuing Education Reimbursement
- Excellent Team Oriented Culture
- Free Gym for Employees
Position: Care Manager (RN)
Location: Monterey, CA
Reports to: Clinical Program Manager
Schedule: Full time, Hourly
Aspire Health Plan’s (AHP), population health department, originally known as Community Health Innovations (CHI), was established to transform healthcare in Monterey County.
AHP is owned by two large healthcare systems -- Montage Health and Salinas Valley Memorial Healthcare System -- partnering to improve the health and well-being of our communities. This collaboration creates a unique opportunity to positively disrupt the traditional provision of medical care by focusing on wellness and empowering individuals to better manage their health.?
We are passionate about improving healthcare value, unburdening clinicians, and inspiring individuals to live their best life. If you want to make a difference, use your talent to help people live healthier, and work with a fun and dynamic team -- AHP might be the place for you!
Purpose of Position
The Care Manager (CM) serves in an expanded nursing role, collaborating with complex patients, their support systems, primary care providers, as well as all providers of care. The CM performs duties to support the goals and objectives of AHP’s model of care management to ensure delivery of quality healthcare that focuses on providing excellent patient care and achieving a high level of patient satisfaction.
The Care Manager oversees care management and care coordination of delegated health care services in their assigned location based on organizational needs, at the discretion of the employer. AHP Care Managers use standardized tools and assessments to track, monitor and coordinate care plans for assigned patients, and ultimately work to graduate patients from care management once patients meet their care plan goals.
Many patients will have multiple conditions and co-morbidities and/or psychosocial needs. The CM will develop an effective supportive relationship with the patient/family to facilitate achievement of individualized health goals. They will interact and collaborate with interdisciplinary care teams which include, but are not limited to physicians, discharge planners, referral coordinators, pharmacists, laboratory technologists, social workers, dietitians, educators, nurses, health plans, and other healthcare team members.
The Care Manager serves as an advocate for patients and their families, providing education on relevant community resources and services for continued growth toward their maximum level of independence. The CM helps patients gain insights and knowledge of their chronic condition to maximize self-management of their condition in the least restrictive level of care.
- Assesses the healthcare, educational, and psychosocial needs of patients and their families.
- Collaborates effectively and fosters team approach with patient/family, the Primary Care Physician (PCP) and care team to develop short- and long-term health goals, along with a detailed Care Plan to achieve those goals.
- Partners with PCPs electronically or by phone to ensure care adherence and integration of evidence-based clinical guidelines, preventive guidelines, protocols, and other metrics to develop patient-centered treatment plans; also initiates or adjusts therapies and promotes proven practice as directed by the practitioner and provides appropriate follow up and monitoring as needed.
- Triages patients to appropriate care service using risk and screening criteria and clinical aptitude.
- Develops and implements self-management plan with patient which prevents exacerbation or intervenes early during acute increased severity of disease or its signs and symptoms.
- Educates and documents patient care plan goals and measures which results in greater control of their health status, mutually agreed upon interventions and progress or barriers.
- Makes referrals to community agencies and resources as appropriate.
- Coordinates with family to facilitate communication.
- Coordinates care efforts for a safe, effective, efficient and patient centered transition along the health continuum.
- During times of patient hospitalization or ER visits, works collaboratively with hospital staff to assess the need for appropriate level of care and develops appropriate action plan with the PCP, patient and family as needed.
- Consults and assists with referrals to hospital/ER, outpatient providers, and community resources as appropriate.
- Participates and presents case studies at interdisciplinary team meetings.
- Intervenes on behalf of the patient and organization to reduce avoidable emergency room visits or unnecessary hospital admissions and readmissions.
- Monitors patient status for appropriate outcomes and addresses clinical issues with the attending physician and care team to optimize outcomes.
- Creatively explores alternatives or work around options with patient and family, to resolve barriers and meet health care goals.
- Maintains collegial relationships with medical neighborhoods, medical suppliers and community agencies/resources available to patients within Monterey County and beyond.
- Ensure patients receive quality services and products in the most cost-effective manner.
- Manages practice metrics to further refine delivery of care model and enhance clinical, quality, and fiscal outcomes.
- Works with population health management division leadership to continuously evaluate processes, identify problems, and propose process-improvement strategies that enhance the Advanced Medical Home delivery of care model
- Uses appropriate conflict resolution, assertiveness, negotiation, and collaboration skills to engage patient and family throughout the healthcare process.
- Works with physician and Care Management leadership to develop protocols and POC reminders using nationally recognized evidence-based care measures and outcomes, such as: Diabetes, HF, COPD and CAD.
- Works with physician, Clinical Program Manager and Director of Care Management to define quality measures/ outcomes reporting process.
- Other duties as assigned
- Problem resolution skills
- Excellent customer service
- Critical thinking skills and ability to analyze datasets
- Proficient with Electronic Medical Records, Outlook, Microsoft Office Word and Excel.
- Demonstrates customer-focused interpersonal skills and interacts effectively with practitioners, the interdisciplinary healthcare team, community agencies, patients, and families who may have diverse opinions, values, and religious and cultural ideals.
- Demonstrates ability to work autonomously and be directly accountable for results.
- Demonstrates flexibility
- Exhibits capability to influence and negotiate individual and group decision making.
- Possesses skills to function effectively in a fluid, dynamic, and rapidly changing environment.
- Displays proven ability to positively influence behavior and outcomes.
- Current Registered Nurse license (RN) in the state of California.
- Minimum one year of current case management experience
- Minimum two years of patient care experience (Hospital, Home health, Skilled Nursing, Physician Office, or Clinic)
- Complete Case Manager Certification (CCM or ACM) within 2 years from date of hire, if not already obtained.
- Experience with electronic medical record documentation.
- Outstanding communication skills, both written and verbal.
- Excellent organizational skills.
- Bilingual English/Spanish
- Bachelor’s degree in social sciences, social work, nursing, or a related field.
- Knowledge of Monterey County community resources & providers.
- Experience as a care manager in an Advanced Medical Home.
- Care experience in a Medicare, Commercial and Medi-Cal environment
- Experience working in EPIC EHR
- Certified case manager (CCM)
- Minimum two years of work experience in public health or related field.
Assigned Work Hours:
Job Status: Full Time
Job Reference #: 2022-1057