RN Chronic Care Manager (Full-Time/Day Shift)

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Summary

Provide primary care management support to patients enrolled in the high-risk Chronic Care Clinic at Roseville Pediatrics. Uses an explicit process to identify patients at risk for poor outcomes, and who coordinates care and support, both within and outside of the pediatric primary care office. The care manager identifies problems in critical pathways, and facilitates teamwork among services required for the effective implementation of a comprehensive high-risk care model.  Integrate and work cohesively with on-going Patient Centered Medical Home primary care redesign projects.  Develop novel care management interventions with the high-risk pediatric population.

Job Description

LOCATION: Roseville Pediatrics

HOURS: Full-time 1.0 FTE (40 hours/week); Monday-Friday; primarily day shift

ESSENTIAL FUNCTIONS: Qualified individuals must have the ability (with or without reasonable accommodation) to perform the following duties:

• In conjunction with the practice team, identify patients at risk for poor outcomes or experiencing poor coordination of services who would benefit from more intensive follow-up within context of the Chronic Care Clinic.
• Conduct assessment of family and patient needs
• Direct patient care (vaccinations, measurements, history gathering)
• Facilitate in appointment making and coordination of information between subspecialists and the primary pediatrician. 
• Identifies appropriate providers, facilities, external healthcare organizations, and community resources throughout the continuum of care and communicates with an interdisciplinary treatment team to develop and maintain positive working relationships with patients, families, and providers
• Help coordinate, along with ACCT team, transportation and other socioeconomic or logistic barriers to care
• Management of problem lists, scanned documents, dashboards, and care coordination grid within Epic for each patient in the chronic care cohort
• Provides chronic disease and self-management education and support to patients and families
• Interceding with insurance companies when needed for coverage and letters of medical necessity.
• Complete care plans in coordination with parents, schools, and home based nurses.
• Provide proactive outreach to patients to include telephonic, internet or face-to-face encounters.
• Coordinating with the ACCT when patients are stable with current care plans and can be transitioned to the next level of care management
• Help coordinate with the PCP for transitions of care for older patients as they transition into adult medicine and PCPs
• Participates with the care team for data collection and collation for the purposes of health outcomes research, clinical audits,  program evaluation related to various initiatives

SECONDARY FUNCTIONS: The following duties are considered secondary to the primary duties listed above:

• Help in identification of best methods to transmit case management plan to all points of care provided in the health care system, and county social service agencies.
• Works together with other staff members on projects, determining scope, timeline for implementation and outcomes.
• Participate in supporting quality improvement implementation of new forms, processes and procedures.
• Other duties as assigned.
• Participates in the on-call responsibilities for this position as required. 

MINIMUM REQUIRED QUALIFICATIONS:

• Registered Nurse (RN)
• One (1) to Three (3) year experience in case coordination and planning as well as experience in project implementation and execution.
• Ideal prior background would also include experience with insurance coordination, including tasks such as prior authorizations, pre-certifications, DME coordination, and coordination with home nursing services. Maintain current professional licensure
• Evidence of experience working among multi-disciplinary teams.

PREFERRED QUALIFICATIONS:

• One (1) to Two (2) years of care management experience, communication, and team building.

Disclaimer: This job description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills, efforts, or working conditions associated with the job.  It is intended to be a reflection of those principal job elements essential for recruitment and selection, for making fair job evaluations, and for establishing performance standards.  The percentages of time spent performing job duties are estimates, and should not be considered absolute.  The incumbent shall perform all other functions and/or be cross-trained as shall be determined at the sole discretion of management, who has the right to amend, modify, or terminate this job in part or in whole.  Incumbent must be able to perform all job functions safely.

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ROSEVILLE Full Time Posted on 09/12/2023