RN, Intense Case Manager

The RN Intense Case Manager (ICM) is a member of a multidisciplinary team whose objective is to assist members, their families, and caregivers navigate the healthcare system and connect them to resources that will meet their healthcare needs and promote general well-being. This role’s goal is to improve a members’ ability to self-manage their care and improve their quality of life by understanding and taking the members’ beliefs, interests and values into consideration while assessing how to effectively support the members’ desired healthcare goals. The RN Case Manager will help determine when the patients are stable for discharge from the Priority Care Program back to their primary provider. Professional Duties

Attend all scheduled patient office visits in the Priority Care Program and execute providers orders in a timely manner.

Responsible for coordinating the overall multi-disciplinary care plan for patients enrolled in the PCC-ICM Program to ensure implementation of plan which includes adequate information and training, while avoiding gaps or lapses of care, duplication or fragmentation of services, etc.

Evaluate patients level of acuity based on clinical criteria and update level and Priority Care physician as needed.

Act as the primary liaison between the ICM patient and their family and the healthcare providers involved in the patients care. Maintain other healthcare providers informed of updates in patient health and status to support continuity of care and well-informed healthcare decisions.

Document all patient communication in NextGen.

Communicate with other healthcare providers and staff involved in the member’s care to coordinate care, organize and plan the members care activities.

Discuss and review the advance health care directives including the Physician Orders for Life-Sustaining Treatment (POLST) so that members can communicate their health care preferences and desires at end of life.

Review and interpret patient medical history, lab results, and prescribed medications to accurately assess patient needs and deliver appropriate education based on clinical findings.

Assess PCC-ICM patients for eligibility and readiness for transition to Palliative Care, Hospice, or other clinical service programs upon stabilization and completion of workup; present appropriate options and facilitate transitions for patients who consent to enrollment.

Coordinate discharge planning by updating the patient's care plan, communicating with the primary care provider, and ensuring all relevant documentation and follow-up appointments are completed to support a smooth transition and continuity of care.

Perform other duties as assigned.

Introduce self and your role

Be an active listener (make eye contact, validate)

Assume a neutral position and suspend judgment of others

Offer to answer any additional questions that the person, patient or customer may have

Anticipate needs that will arise before your next meeting

Serve as an ambassador for Desert Oasis Healthcare and Family Hospice Care at all times and positively shape the customer experience

Be knowledgeable about your job so that you can serve others effectively

Be accountable for your work

Be sensitive to factors that influence customers and co-worker’s situation including age, gender, culture, race and socioeconomic status. Be observant of others’ social cues (emotions) and respond appropriately Qualifications

Completion of an accredited nursing program. Current California Registered Nurse (RN) license.

2 years of RN experience involving direct patient care with interaction with patients and family members in an acute care setting required. Case management experience preferred.

Ability to effectively communicate with individuals within all levels of the organization, patients, patient family members, providers, coworkers and others.

Ability to use Microsoft Office applications (Excel, Outlook, Word etc.) and other computer software applications.

Detail oriented. Ability to prioritize tasks to meet established deadlines and prioritize tasks as the need arises.

BLS required within 60 days of hire. Physical Demands

Sitting: Approximately 40% of day.

Standing: Approximately 25% of day.

Walking: Approximately 35% of day.

Lifting: 0 - 40 lbs. approximately 15% of day.

Bending: Approximately 10% of day. Kneeling < 20%.

Hearing/Visual Acuity: Adequate for use with computers, telephone/cellphone, and other office tech equipment approximately 50% of day.

Computer: Highly technical work environment. Must be able to work > 7 hours per day using computers, telephone/cellphone, and other office tech equipment.

Reaching: Above head 75 degrees approximately 5%.

Hand grip dexterity: Approximately 40% of day.

Customer communication, Microsoft Excel, Microsoft Outlook, RN License, Acute care facility experience, Desktop applications