Under the direction of the Clinic Supervisor, this position is responsible to assess, diagnose, plan, implement, and evaluate the patient to facilitate and coordinate the patient's plan of care with the provider. The RN Case Manager will interact with other departments, clinic personnel, and outside providers in a professional and friendly manner, to create and maintain a positive relationship with our internal and external customers.

• Maintain patient confidentiality.
• Be flexible and adaptable.
• Obtain and document all pertinent patient information and notes in NextGen.
• Strive for positive and professional relationship with providers, patients, and families.
• Provide effective communication with various health care providers, including specialists.
• Attend all scheduled patient office visits and execute provider orders in a timely manner.
• Evaluate patient's level of acuity based on the clinical criteria and update level with changes in patient health status.
• Level 1A - 99100 - HIGH acuity - Weekly Case Manager follow up - End Stage health conditions, severe, acute and/or chronic health concerns.
• Level 1B - 99101 - MODERATE acuity - Bi-Weekly Case Manager follow up - multiple co-morbidities, acute and chronic health concerns, recent hospitalizations.
• Level 2A - 99102 - LOW acuity - Monthly Case Manager follow up - stable, needs minimal follow up, conditions well controlled, near return to PCP.
• Complete annual intake assessment with RN's reviewing LVN documentation.
• Including patient's self-management plan, goals, barriers, and progress toward goals, caregiver resources, psychosocial assessment, DME, mental health status, medical status, medication review, etc.
• Create a comprehensive and working care plan following NCQA, CMS, & Health Plan guidelines, with input from the IDCT and patient or caregiver.
• Incorporate the completed HRA, provided by the Health Plan, into the care plan.
• Set and prioritize appropriate patient centered goals.
• Update care plans with changes in patient's medical status.
• Be knowledgeable regarding disease processes and medications to ensure the ability to assess patient needs and provide education as indicated.
• Ensure the patient progresses through the continuum of care by coordinating the integration of social services, case management, patient care needs, and home planning processes.
• Coordinates the provision of Social Services and/or Patient Services Coordinator to patients and families to enable them to cope with the impact of illness on individual family functioning and to achieve maximum benefits from healthcare services.
• Mobilizes resources and intervenes, as needed to achieve expected goals to assist in achieving desired clinical outcomes within the desired timeframe.
• Ensure patient tests are appropriate and necessary and are carried out within the established timeframe and that the results are promptly available.
• Collaborate with clinical staff in the development and execution of the plan of care and the achievement of goals.
• Ability to be proactive with treatment options.
• Aggressively assist in information gathering to allow for insightful decisions.
• Strive for timely admissions and discharges from Priority Care Clinic.
• Ensure a smooth transition of care back to Primary Care Provider after discharge from Priority Care.
• Initiate/participate in Code Red, Code White and Code Blue situations as directed.
• Requires familiarity with the clinical structure of BFMC and the health care services with which it contracts.
• Understand patient healthcare benefits and help establish expectations for services within those benefit limits.
• Establish and maintain a functional familiarity with all contract services with which we deal.
• Be familiar with all policies, procedures and documentation related to the SNP Program.
• Ensure reporting (annually and/or transitions of care) for SNP patients in IDT Meetings.
• Educate and assist in decisions regarding end-of-life care including Advance Directive Forms, Durable Power of Attorney, POLST Forms, etc.
• Facilitate any Transitional Care needs and ensure follow-through on all discharge orders.
• Participate in the Utilization Review process regarding any assigned patients ensuring proper hand off report to U.R. Case Manager. Attend Utilization Review meetings as directed.

• Graduate from an accredited Registered Nursing program.
• Current California RN license.
• Current BLS certification.
• Minimum of two years clinical nursing experience.
• Ability to utilize electronic mail effectively.
• LVN case managers must be overseen by an RN, which may be met by RN Clinical Auditor oversight.

The pay range for this position at commencement of employment is expected to be between $53.77 and $63.26. However, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience.

If hired, employee will be in an "at-will position" and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.