Community Care Registered Nurse (Hybrid)

Position Summary:

Reporting to the HCBA Waiver RN Supervisor, and as a member of the Care Management Team, the Community Care, RN (HCBA Waiver RN) coordinates an interdisciplinary approach to support continuity of care. This role develops and monitors the plan of treatment for a caseload of the Home and Community-Based Alternatives Waiver program participants and provides community-based (in-home and telephonic) care management services to ensure the health, safety, and well-being of vulnerable and high-risk populations. This includes providing utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed by members. This position works closely with all members of the Care Management Team to develop, evaluate, and monitor service and care coordination plans that have a direct impact on improved outcomes and cost containment.

Essential Functions of the Position:

• Responsible for the proactive management of acutely and chronically ill patients with the objective of improving health outcomes and costs by developing a detailed plan of treatment that reflects an appropriate nursing assessment of the care management applicants, interventions, and the potential participant’s primary care physician’s orders.
• Monitor patient outcomes and plan of treatment efficacy in accordance with mandated timeframes and program guidelines either telephonically or during an in- person home visit. Inform the primary care physicians of the participant’s progress.
• Assess quality and clinical risk issues on a concurrent basis, reporting any recognized issues according to program policy.
• Develops strong working relationships with external contracted providers, case managers, and admissions department/personnel.
• Assess documentation of medical records for completeness and relationship to the treatment plan and identify gaps or barriers in treatment plans.
• Facilitates on-going communication between staff and contracted providers to ensure authorizations are secured in a timely and efficient process.
• Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the facilities and service providers.
• Participates in Utilization Management team meetings, as needed, reviews, and discusses with providers evidence-based care options and proposes alternative levels of care.
• Conducting a comprehensive health and psychosocial assessment of participants’ medical needs, diagnosis, functional and cognitive abilities, and environmental and social needs, to determine which service(s) are required to meet participants’ needs and preferences in the community.
• Working with the participants, their legal representatives, circles of support, and/or primary care physicians and providers to:
• Develop goals associated with the participant’s assessed needs, individual circumstances, and preferences.
• Mitigate risk and minimize disruptions in services.
• Identify when services identified in the POT are available through friends, family, and/or publicly funded programs.
• Implement the POT, which includes identifying service providers and community resources to help assure the timely, effective, and efficient mobilization and allocation of the services.
• Identify (and train, if necessary), backup caregivers who are willing and able to provide unpaid support if and when waiver service providers do not arrive when scheduled.
• Provide information, education, counseling, and advocacy to, and on behalf of, participants.
• Establishing a care coordination schedule based on the needs and acuity of the participant as determined by their initial service needs assessment and subsequent reassessments.
• Monitoring the delivery of program services to ensure participants are receiving services as authorized in their POTs.
• Monitoring the quality of the authorized services by maintaining ongoing contact with participants (including a monthly face-to-face visit or telephone call) to monitor for changes in health, mood, social integration, functionality, and overall well-being.
• Conducting annual face-to-face visits, reassessments, and care plan updates; and, following up with the participant after Emergency Department and inpatient facility admissions.
• Maintain accurate case management records and timely documentation standards.

Additional Duties and Responsibilities:

• Works independently and as an effective member of the team.
• Ability to manage projects and their respective activities, timelines and issues.
• Demonstrate ability to inter-relate with physicians, nurses, patients, internal departments, outside agencies, and the public.
• Demonstrate customer-focused service skills.
• Knowledge of HMO and Waiver program regulations related to eligibility requirements and plan specifics.
• Working knowledge of InterQual or other evidence-based care guidelines.
• Basic physical, psychosocial, and functional assessment skills.
• Able to collaborate between organizational and community resources.
• Thorough knowledge of appropriate utilization of acute hospital, long-term care and home care resources.
• Able to document concise yet thorough clinical documentation of patient assessment and care needs.
• Demonstrated strong communication and customer service skills, problem solving, critical thinking, time management, organizational skills and clinical judgment abilities.
• Familiarity and ability to use computers as well as EHR’s.
• Complies with all department, organization and government policies & procedures.
• Attends meetings and trainings as required.
• Adheres to and models SYH’s core values and behaviors of Excellence, Empowerment, Integrity, and Respect.
• Adheres to SYH attendance and punctuality policies and practices.
• Performs other duties as assigned.

Job Requirements

Experience Preferred:

• 2 years of experience working in a managed care health plan and/or
• 2 years of experience in utilization review, case management, discharge planning and/or
• 2 years of experience in transitional care and acute care settings (critical care, acute hospital care, long term acute care, skilled nursing care, long term care) and/or
• Knowledge of and/or experience with Managed Care Health plans, Medi- Cal/Medicaid, and/or Medicare
• Demonstrated ability to be culturally sensitive and respect diversity, work effectively with individuals of different cultures and socio-economic status.
• Passion for service.
• Self-starter and highly organized.
• Ability to prioritize and complete a large volume of work within strict deadlines.
• Provide prompt, efficient, and responsive customer service.

Education Required:

• High School Diploma/GED
• Graduate of an accredited registered nursing program.

Education Preferred:

• BSN or MSN Degree

Certifications Required:

• Current California RN licensure required.
• Current Basic Life Support (BLS) Certification.

Verbal and Written Skills Required to Perform the Job:

• Ability to read, write and comprehend medical information and terminology.
• Ability to effectively present information, both verbal and written.
• Ability to effectively document in EMR (efficient typing, thorough progress notes and navigation of EMR).
• Good knowledge of Microsoft Applications including Word, Excel, Access and Power Point. Computer data entry, analysis and reporting experience required.

Technical Knowledge and Skills Required to Perform the Job:

• Must thrive within a team environment, possess good organizational skills, and have the ability to effectively handle difficult and unusual interpersonal situations.
• Knowledge of Electronic Health Data Systems.
• Knowledge of managed care regulations (state and federal).

• Principles and practices of health care service delivery, managed care, health care systems, and medical administration.
• Experience performing audits analyzing productivity and quality of utilization management
• Knowledge and/or experience with the senior care market, including competitors, regulations, and available resources.
• Experience in the application of InterQual criteria or other evidence based medical criteria.

Equipment used:

• Personal vehicle, computers, phones, copy machines, fax machines and other general office equipment.

Working Conditions and Physical Requirements:

• Physical clearance for reaching, bending, stooping, crouching, kneeling and grasping.
• Have full range of motion.
• Ability to lift 50 lbs.
• T.B. clearance.
• Must maintain current First Aid and CPR.
• Frequent standing and walking indoors and outdoors.
• Will be required to travel to other sites or other locations in San Diego County and Imperial County.
• May be required to work some evenings and/or weekends.

Universal Requirements:

Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs. Compliance with all mandated vaccinations and all boosters is a term and condition of employment.