As our RN Care Coordinator, you will coordinate care and collaborate with multiple disciplinary team members across the continuum of care to improve the quality of care and clinical outcomes for members with complex care needs.Every day you will conduct thorough assessments to determine unmet needs and develop individualized care plans, evaluate and identify knowledge gaps in disease process and treatments, determine appropriate resources or services required to meet an individual's health needs, and provide education/coaching on disease self-management for health promotion and maintenance. You will promote quality cost-effective outcomes with the goal of improved care coordination amongst providers and increased involvement of the individual family and/or caregiver in the decision making process to reduce hospitalizations, readmissions and ER visits. You will conduct both telephonic case management and direct patient contact through follow-up at clinic appointments and/or home visits, as needed.To be successful in this role, you must show compassion, use your critical thinking skills, and remember that each patient requires a custom care plan tailored to their needs. Your talent for creative thinking is vital to your success in care coordination and it will shine as you develop enhanced care plans, yielding optimal outcomes for each patient.

This position is hybrid in-office/clinic (Midtown Sacramento clinic) and work from home.

• Concurrently reviews patient's records to collect data to carefully understand the needs of the patient by scrutinizing their background history, understanding their current needs, and arranging for their wellbeing.
• Coordinates with other disciplines to facilitate the patient's individual needs. Makes plans to resolve unexpected care requirements. Anticipates and identifies variances in the care process related to those identified needs.
• Assists in development, implementation and revision of individual care plans; assures that services provided are specified in the Care Plan and monitors progress toward goals, including documentation of daily improvement in patient's condition or otherwise notes lack of improvement for reassessment of appropriateness of care plan.
• When barriers are identified, assists the patient and the family/caregiver in developing, documenting and implementing appropriate care plans to access agencies, resources and care providers.
• Teach, coach and educate the patient, family and/or caregiver about their disease process to recognize signs and symptoms of worsening disease and how to take appropriate measures.
• Documents patient, family or caregiver's knowledge regarding medical condition(s), and indicates when condition is worsening and develop a plan for how to respond.

Required

- Two (2) years clinical experience as a RN in acute, ambulatory care, home health, skilled nursing facility, medical group, or health plan setting required. A Masters Degree in nursing with a concentration in Case Management can serve as a substitute for the experience requirement.- Current CA Registered Nurse (RN) license- Excellent customer service and presentation skills are a must- Strong interpersonal and written communication skills are essential- Demonstrated ability to apply analytical and problem solving skills- Ability to demonstrate leadership skills to delegate and provide direction/guidance to multidisciplinary teams- Demonstrated ability to manage multiple tasks or projects effectively- Ability to work independently as needed with a high degree of detail orientation- Ability to work efficiently in a fast-paced environment with changing priorities- Knowledge of regulatory and accreditation standards (URAC NCQA) and complex case management (CMSA)- Knowledge of community resources- Knowledge of capitation/HMO insurance payers and government healthcare plans and audit

Preferred

- Prior Care Coordination experience in a clinical or insurance setting is required. If operational conditions permit training a candidate without the required experience may be considered.- BSN degree or experience equivalent preferred- Case Management (CM) certification preferred