RN Care Manager Ambulatory Services Rosecrans Clinic
Company: Martin Luther King, Jr. Community Hospital
Location: Monterey Park
Posted on: January 13, 2022
If you are interested please apply online and send your resume
Under the general direction of the Site Administrator Ambulatory,
provides transitional and chronic care management; Identifies
eligible patients, advocates for enrollment, assesses patient needs
and barriers to care, then collaborates with the patient's care
team to tailor care plans, services, and resources to meet the
individual needs of the patient and caregiver;Remains skilled in
interpersonal communication and motivational interviewing to help
promote patient and caregiver engagement and self-management; Makes
routine contact based on patient complexity to help the patient and
caregiver. Develop goals, monitor outcomes, and evaluate patient
readiness for graduation from the program.The overall goal of the
RN Care Manager is to improve the health of populations, improve
the patient experience, reduce readmissions, reduce utilization of
higher cost healthcare, and promote patient and caregiver
engagement and self-management.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Coordinates with the Primary Care Providers, and all members of the
health care team to facilitate a strong transitional healthcare
pathway for the patient. Monitors patient's healthcare pathway to
ensure adherence, removes obstacles and identify progress toward
desired care outcomes; intervenes to overcome deviations in the
expected plan of care; reviews the care plan with patients in
conjunction with the direct care providers; interacts with involved
departments to negotiate and expedite scheduling and completion of
tests, procedures, and consults. Works with patients and their
family members to develop a personalized healthcare pathway that
meets the individual's needs on both a short term and long-term
basis. Orients and educates patients and their families about the
healthcare pathway by meeting them; explaining the role of the RNCM
initiating the health plan; providing educational information in
conjunction with health care team related to treatments,
procedures, medications, and continuing care requirements.
Identifies high-risk patient's to promote coordination of services
and to prevent readmissions or Emergency department visits. Disease
Management Assists in the management of patients with chronic
diseases following established protocols and systems for disease
management in collaboration with providers. Assesses patient
learning needs and has the ability to develop and implement
individualized educational or care plans. Reviews, evaluates and
revises the plan on an ongoing and timely basis. Communicates with
a multidisciplinary team (physicians, nurses, therapists, social
workers, etc.) as needed to assist with disease management.
Develops self-management goals and monitors the progress of the
goals. Has the ability to oversee and assist the patient with
referral navigation. Initiates disease-specific care conferencing
as needed. Utilizes patient communication strategies, e.g.
motivational interviewing, to involve the patient in developing a
plan of care, goals or other specific measures pertinent to their
health condition. Assesses patient activation and readiness for
change and uses these to develop self-management goals.
Participates in confidence level assessments or surveys of patients
to improve disease management care delivery processes. Documents
all disease management encounters using standardized processes.
Bachelor of Science degree in nursing preferred.
Minimum of one (1) to three (3) years of hospital inpatient or
related experience required. Able to navigate and connect
successfully with outside provider networks (Health Plans, IPA's,
and FQHC's). Current California Nursing license Certification in
Case Management preferred.
C. Special Skills/Knowledge
Bilingual language skills preferred (Spanish) Basic computer skills
Current Basic Life Support (BLS)
Equal Rights Employer
Applicants are considered for positions without discrimination on
the basis of race, color, religion, sex, national origin, age,
disability, genetic information, citizenship status, military
service, or any other status protected by federal, state, or local
laws. This application is intended for use in evaluating your
application for employment. Please click the link below to view the
E-verify or Right to Work information.
MLK Community Healthcare
1680 E 120th Street
Los Angeles, CA 90059
Keywords: Martin Luther King, Jr. Community Hospital, Monterey Park , RN Care Manager Ambulatory Services Rosecrans Clinic, Executive , Monterey Park, California
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