Rn - Care Manager

Job Details

• Opportunity to work in a dynamic, fast paced and innovative care management company that is transforming the delivery of kidney care.
• This position will work with underserved populations.
• 6 Patients per Day for Telehealth
• Laptop, mileage reimbursement, phone allowance, and extra perks available!
• Flexible paid leave and vacation policy.
• Negotiable salary and bonus.
• 4 Patients per Day for Home Visits
• 3-4 Days of Home Visits (within 1 hr driving radius of assigned territory) and 1-2 Days of Telehealth

Job Summary
This is a care management position, in which Care Manager – RNs will create and administer care plans, rather than rendering direct clinical services. Care Managers – RNs lead the effort to help prevent costly and traumatic episodes such as avoidable hospitalizations, re-admissions, and unexpected kidney failure. For those already on dialysis, Care Managers – RNs provide additional support, particularly around transitions in care such as hospital discharges.
Responsibilities

• Review and document plan member updates and progress in care management platform
• Prepare care recommendations and escalations for plan members, write reports regarding the same and communicate the same in weekly internal case rounds
• Engage positively with social workers to facilitate social and behavioral needs to of plan members
• Perform plan member health assessments and surveys as required
• Use personal communication skills, patience and diligence to engage plan members and their caregivers
• Monitor biometric data and follow approved protocols for any necessary interventions
• Understand the needs of the health plan managed care clients and prioritize plan member visits, recommendations and focus accordingly
• Deliver individual and group education on CKD, ESRD, dialysis and associated co-morbidities
• Develop and continually adapt an individualized care plan in conjunction with physicians
• Coordinate with dialysis providers to ensure transitions of care are seamless
• Encourage medication and treatment adherence through frequent contact with members
• Educate members and facilitate conversations around proactive care decisions, especially relating to transplantation, home modalities and proactive AV fistula placement
• Serve as the primary point of contact and be the first call when members have questions about their health
• Perform frequent daily in-home care management visits to execute care management plans
• Inventory and reconcile medications and coordinate with pharmacists and prescribers
• Perform post-op and hospital discharge visits to help plan members through vulnerable transitions

Requirements

• Ability to drive to patients’ homes
• Ability to take call remotely on some nights and weekends
• California RN license with no restrictions
• Bilingual in English and Spanish a plus
• 1 year of nursing experience
• Graduate of an accredited school of nursing