ECM Case Manager RN

PRIMARY PURPOSE: Under direction of the Administrative Director of the Enhanced Care Management, Enhanced Care Management RN Supervisor and KHS Medical Director, the ECM Case Manager RN is responsible for working collaboratively with the  KHS distributive care team members and leadership of assigned ECM sites., providing guidance and support with Certified Case Manager (CCM), specific in the completion, over site and reporting for the programs core measures defined in the State mandated Enhanced Care Management (ECM) Program This collaboration will ensure that each member is receiving all required services for their physical, behavioral, and social needs. They will act as a resource and liaison, assisting members in navigating the healthcare system to facilitate the appropriate delivery of care and services. These services are provided utilizing available resources across a continuum of care and in collaboration with ECM sites, community-based services, and community providers.     CLASS CHARACTERISTICS: Incumbents in this position are fully competent in all essential areas of case management and are expected to use an advanced level of judgment in the discharge of their duties. Case Managers work independently under general direction. This position involves frequent communication with ECM site leadership, ECM leadership, KHS Medical Director, medical providers, and KHS staff telephonically, electronically, and potentially in-person.   SUPERVISES: None     MAJOR DUTIES & RESPONSIBILITIES: Conduct Case Management (CM)assessments on members enrolling and already enrolled in the ECM Program   Working closely with internal systems and KHS CM for referral of members who do not meet ECM eligibility but can still benefit from other services within KHS. Monitors and evaluates the effectiveness of the ECM program by doing regular audits at defined intervals to ensure compliance of program guidelines. Reviews and processes all incoming referrals (both internal and external) to check for eligibility and those not listed as ECM eligible, for evaluation of possible eligibility. Contribute to and develop individualized care plans for members based on assessments to be reviewed with the ECM Provider Engage with the member to implement the care plan to make progress towards the care plan goals Oversite/auditing and review of individualized care plans to ensure members have a solid plan of action with clearly identified, achievable objectives, focused on modifiable risk factors Provide written and verbal communications regarding oversight and auditing outcomes with ECM Sites, ECM RN Supervisor, and Admin Director of ECM to ensure compliance with ECM requirements and provide corrective action measures if indicated.  Work with community providers as a liaison and with the referral process and participate in member case conferences if needed. Assist with submissions and approvals of requested authorizations to ensure timely member specialty services and/or scheduling. Recognize members’ right to participate or refuse participation in the ECM. Participates, as needed, in care management conferences for members with complex medical needs. Document all CM assessments notes in accordance with professional standards in a thorough and timely manner. Communicate, consult and collaborate with KHS Administrative Director of ECM, ECM RN Supervisor and Medical Director on an as needed basis. Serve as a liaison to community providers and KHS ECM Members. Collaborate with KHS staff to facilitate production of reports necessary monitor and identify ECM performance and GAPS in care to report back to sites for completion.   Monitoring of outreach activities and benchmarks for enrollment at assigned sites. Monitoring timeliness of transition of care discharges and appointments. Provide training to ECM staff to ensure compliance with DHCS requirements and program goals Perform other related duties and special projects as assigned.  DISTRIBUTIVE MODEL:   Provide leadership within the ECM distributive care team to ensure that the DHCS defined core measures are being met for all ECM enrolled members.   Work collaboratively with the Care Coordinator (CC) to ensure completion of health assessments and screenings. Collaboratively create and implement the members individualized care plan, incorporating the needs and goals of the members medical, behavioral and social needs Assign members in appropriate targeted risk category for the implementation of category-based interventions and treatments that are planned to enhance the member's outcomes. Serve as liaison to clinic based primary care physicians and specialists to engage providers in care plan development and follow-through with a goal of ensuring cost-effective quality care. Provide consultation to CC on medical prioritization of a member’s care plan and outreach to medical care team members (such as PCP, Specialist, Hospitalist, and ancillary providers) as needed Collaboratively initiate, present and participate in ICT conferences with the care team, Provider and patient. Work with the Care Coordinator to identify, contact and coordinate members experiencing care transitions and coordinate care across settings and helps client/caregivers understand health care options. Engage in ongoing interdisciplinary, intra-organizational collaborations and serve as a nurse liaison to KHS partners, Behavioral Health, governmental agencies and community-based organizations (such as CCS, CBAS, IHHS, Homeless Authority etc.). Coordinate with Pharmacy teams on members medical and pharmacy needs. Provide targeted medical interventions focused on chronic condition, assessment and management, prioritization of medical needs health coaching education, and development of member’s self-management skills. REQUIREMENTS:   CORE COMPENTENCIES / KNOWLEDGE & SKILL REQUIREMENTS Lead by example to support a positive work environment that values patient advocacy, respectful listening, diverse expression of opinion and constructive conflict resolution; Adheres to KHS’s Code of Ethics and Business Conduct and all company policies; e.g., confidentiality, attendance, safety/security, use of equipment and technology, appearance and demeanor; Represent KHS in a positive manner to all members, caregivers, staff and external stakeholders; Demonstrate commitment to continuous improvement; Strong knowledge of acute chronic care nursing principles, methods and common treatments; Demonstrated knowledge of medical terminology; Ability to effectively evaluate medical records to determine appropriateness and necessity of care; Demonstrated knowledge of health care delivery systems; Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individual at all levels both inside and outside of KHS; Ability to use tact and diplomacy to diffuse emotional situations; Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards; Intermediate skills in Word and Excel with basic ability to enter data into and navigate through a database; Demonstrated ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, KHS business or employee information and make no disclosure of such information except as required in the conduct of business; Demonstrated ability to commit to and facilitate an atmosphere of collaboration and team work; Self-directed, with proven ability to work independently with minimum supervision; Demonstrated ability to multi-task in an interrupt-driven environment and complete assignments on a timely basis; Strong attention to detail; work accurately and at a reasonable rate of speed; Compliant with KHS policies and procedures; performs the job safely and with respect to others, to property, and to individual safety.    Employment Standards:   Education:  Registered Nurse (RN) with an active, current, unrestricted license Bachelor’s Degree in Nursing from an accredited school or equivalent, Health Administration or related healthcare field preferred. Obtain Certified Case Manager (CCM) Certificate within 12 months of hire REQUIRED Experience: Minimum of two years (2) full-time clinical experience in acute care, community health setting, public health nursing or chronic disease management required; Experience working with patients and caregivers regarding self-care and disease management required; Experience working in out-patient case management or care coordination is a plus; Knowledge of Kern County Community resources for chronically complex members is a plus; Other Possession of valid CA driver’s license and proof of State required auto liability insurance. Required Travel Up to 50% Bilingual (English/Spanish Preferred)

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