Provides patient-centered case management to patients with chronic illness, complex medical conditions and who are in transition across the continuum of care settings. As a member of an interdisciplinary team coordinates care in accordance with the plan of care, to achieve optimal results by impacting the delivery of quality care in a holistic approach to the patient and family. Provides assessment, treatment, intervention, patient education and patient management for adult/child patients and th... more details
Organization:
SHSO-Population Health Services-Bay
Position Overview:
Provides patient-centered case management to patients with chronic illness, complex medical conditions and who are in transition across the continuum of care settings. As a member of an interdisciplinary team coordinates care in accordance with the plan of care, to achieve optimal results by impacting the delivery of quality care in a holistic approach to the patient and family. Provides assessment, treatment, intervention, patient education and patient management for adult/child patients and their families based on approved standard protocols and within scope of practice.
Job Description:
These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).
JOB ACCOUNTABILITIES:
Prepares intake summaries, treatment plans, and case summaries; documents patient's treatment and progress in accordance with regulations and in keeping with accepted community standards.
Develops, coordinates, evaluates and implements treatment plans with patient centric goals and objectives.
Reviews treatment plan with treating physician for approval prior to implementation and on a regular basis thereafter.
Instructs and counsels patients and their families regarding compliance with prescribed therapeutic regimens and adherence to prescribed medication regimens, within the scope of practice.
Monitors treatment plan for compliance, makes routine follow-up assessments, evaluates patients response to treatment, modifies treatment plan as needed, and provides timely recommended changes in treatment to treating physician.
Makes independent assessments and recommendations regarding course of action in complex situations, such as multi-system or special needs. Identifies potential barriers, prevents and/or resolves variances to the care management plan.
Effectively addresses resistance and/or conflicts related to patients and families.
Collaborates with the physician, patient/family and/or payer to resolve conflicts regarding the treatment plan. Actively participates in case review with physicians and multidisciplinary team members to effectively coordinate care.
Provides focused patient and family education regarding diagnosis, disease process, prognosis, medication regimen and treatment plan.
Educates and counsels patients and family about symptom management and/or physical limitations. Reinforces patient learning by providing approved educational material.
Maintains accurate, current, documentation of patient records using electronic health record and other department forms including patient assessments, plans, and outside agency forms.
Complies with all reporting requirements for risk management and other medical and legal agencies in a manner consistent with confidentiality policies and department standards.
Identifies care needs, nursing assessment, and collaborates with multidisciplinary team both inside and outside the Sutter Health System, patient/family, insurance companies and community based support services.
EDUCATION:
Graduate of an accredited school of nursing
CERTIFICATION & LICENSURE:
RN-Registered Nurse of California
BLS-Basic Life Support Healthcare Provider
TYPICAL EXPERIENCE:
2 years recent relevant experience.
SKILLS AND KNOWLEDGE:
Comprehensive knowledge of a broad range of medical diagnoses, treatment modalities, therapeutic services and intervention techniques, and knowledge of hospital and/or ambulatory practices and procedures.
NCQA standards and application, state and federal requirements as apply to managed care, utilization management criteria and its application.
Knowledge of the health care financial environment and requirements for various payer types, e.g., Commercial, CMS, CCS for HMO and PPO cases, and ability to
apply Managed Care concepts.
Interpersonal skills collaborating with physicians, patients, families, care givers, service providers, and health care team.
Must exhibit , clear oral and written communication skills, including the ability to effectively organize ideas and data for logical presentation and acceptance by
staff; flexibility and knowledge in problem solving activities.
Demonstrated , positive interpersonal relationship skills, to include presentations to small groups, and skill in time management.
PHYSICAL ACTIVITIES AND REQUIREMENTS:
See required physical demands, mental components, visual activities & working conditions at the following link: Job Requirements
Job Shift:
Days
Schedule:
Full Time
Shift Hours:
8
Days of the Week:
Monday - Friday
Weekend Requirements:
None
Benefits:
Yes
Unions:
No
This position is work from home eligible.
Position Status:
Non-Exempt
Weekly Hours:
40
Employee Status:
Regular
Number of Openings:
1
Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.
Pay Range is $0.00 to $0.00 / hour
The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package.
Qualified applicants with arrest and conviction records will be considered for employment. Applicants for specific positions are still required to disclose certain convictions during the application process, and those convictions may also be considered in determining eligibility for employment in accordance with applicable law.
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