Complex Case Manager

High Desert Medical Group•Lancaster, CA

1d•$29 - $39

About The Position

High Desert Medical Group is looking for a full time Complex Case Manager. The principal objective of this position is to develop an appropriate collaborative plan of care, to include but not limited to the following disease processes: congestive heart failure, coronary artery disease, chronic kidney disease, diabetes, chronic obstructive lung disease, cancer, and dementia/Alzheimer's disease. They are responsible for coordination of all ancillary services necessary to provide patient and participating caregivers with all medical and social services to facilitate deliver of care in a safe environment.

Requirements

High school graduate or equivalent.
Graduate from an accredited Licensed Vocational or Registered Nurse program.
Current LVN or RN license.
Current CPR/BLS certification.
Minimum one year experience as a Case Manager in Acute Care, Skilled Care, or equivalent.
Minimum two years clinical nursing experience (Acute Care, Skilled Care, CM or IM medical office location).
Experience with Microsoft Office Suite.
Excellent written and verbal communication skills.
Ability to handle and prioritize tasks in order to meet all given deadlines and productivity goals.
Ability to responsibly handle matters of a confidential nature.
Ability to work in a multi-task, high productive environment.

Nice To Haves

Experience with electronic medical records preferred.

Responsibilities

Identify complex case patients based on enrollment criteria.
Manage/monitor patients, including but not limited to: daily/weekly phone calls, home visits and/or PCP office visits.
Create and maintain working files/logs and/or tracking systems for each patient to ensure proper follow-through.
Document appropriate and pertinent information in patient charts and q.Health (HMO and ACO).
Follow up on patients by making necessary calls to patients/families/providers to optimize continuity of care and minimize resource utilization and hospitalizations.
Utilize in-house, social service, health plan, and community resources available to provide appropriate education and care delivery required to optimize patient health and welfare.
Conduct home visits and/or make recommendations for support staff (RT, LCSW, Medical Provider) that provide home visits to facilitate needs that optimize patient care and safety.
Communicate with provider and provider staff to ensure necessary required paperwork, e.g., lab/test results from hospital, etc., are available for review by provider before or at time of patient appointments.
Attend CCM Forensic and staff meetings as requested.
Communicate with physician/provider and nursing staff to ensure appointments are being kept.
Coordinate with PSA appointment scheduler to ensure patients are being scheduled appropriately and in a timely manner.
Assist in generating needed referrals for patients in order to expedite care, optimize health and/or prevent exacerbation of disease process. Document and ensure receipt of supplies and/or services ordered.
Maintain a collaborative relation with the ancillary support departments to ensure patient education, materials and referrals for other avenues/efforts are completed to assist in patient adherence to treatment program.
Function as liaison between in-patient and out-patient delivery systems to facilitate continuity of care.
Develop and maintain current and relevant patient care plans, goals and interventions, assessments and advanced directives according to department guidelines.
Assist in documentation of non-compliance for processing of health plan notification.
Comply with CCM on-call guidelines.
Comply with hospital visit expectations.
Perform other duties as assigned.