The Care Management Nurse will co-manage cases with the Care Management Community Coordinators (CMCC) and provide medical care management to SFHP members assigned to care management services. This position will be based within the SFHP office but will involve as needed time in the community (at clinics and hospitals, with community-based organizations, and home visits). The nurse will conduct medical assessments, chronic condition education aimed at self-management, medication reconciliation, as well as provide medical/nursing ongoing consultation to the CMCC. The RN will be responsible for co-managing a range of members in different programs. This will require attention to detail and the ability to adhere to multiple workflows and documentation standards. The Care Manager Nurse will work closely and have regular supervision with their assigned LCSW Supervisor, participate in bi-weekly RN group supervision meetings, consultation with Medical Director and ongoing participation in interdisciplinary meetings.
WHAT YOU’LL DO
- Coordinate care management/ coordination of care activities with the assigned CMCC and ensure all medical needs are addressed.
- Ability to provide nursing input on all co-managed cases with the CMCC; up to 150 cases at any given time.
- Responsible for performing care management within the scope of licensure for members with complex and chronic care needs
- Provide consultation to CMCC 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
- Perform duties electronically, telephonically or in person for case management or coordination of care. Primary duties may include, but are not limited to:
- Conduct medical assessments to identify individual needs and inform creation of member-centered care plan in collaboration with Community Coordinator
- Coordinate with Utilization Management and Pharmacy teams on members medical and pharmacy needs.
- Ensures member has access to services appropriate to their health needs.
- Monitor and routinely update the nursing care plan goals and interventions to match member’s motivation and priorities and interfaces with member’s PCP and SFHP Medical Directors on the prioritization of goals.
- Collaboratively initiate and participate in care conferences
- 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.
- Coordinate care across settings and helps client/caregivers understand health care options.
- Review member’s medical history in multiple Electronic Medical Records (EMRs) and summarize key medical information in our care management system, Essette.
- Coordinate care to support access and care continuity, especially during transitions of care. Advocate for safe discharge planning in collaboration with hospital discharge planners and SFHP Utilization Management.
- Role in transitions of care could include but is not limited to:
- Advocacy and support for member’s care plan goals while patient is hospitalized. May include providing background information to hospital staff/discharge planning staff regarding discharge
- Post discharge follow up and care planning including activities such as: medication assessment and reconciliation, disease specific nursing education related to care transition ( wound care, signs symptoms to warrant medical follow up etc), accompany patient to follow up appointment
- Work collaboratively with SFHP UM inpatient/concurrent review and prior authorization staff to ensure members’ care plan goals are achieved.
- If indicated, perform Initial Medical Assessment for new inpatient members referred into Care Management ( i.e. during the hospitalization)
- Add nursing/medical perspective to interdisciplinary team management of clients with complex needs.
- Engage in ongoing interdisciplinary, intra-organizational collaborations and serve as a nurse liaison to SFHP partners, Behavioral Health, governmental agencies and community based organizations (such as CCS, GGRC, LEA, etc.).
- Work collaboratively with Community Coordinators to –assess client’s psychosocial and medical needs and identify/prioritize care planning goals
- Use nursing/medical expertise and experience to support team outreach, engagement, and ongoing management of members regarding chronic disease management, health services use, and medication management.
- 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.
- This position does not directly manage personnel, but requires team work with licensed and non-licensed staff.
- This position is based at SFHP, but will also require travel within San Francisco as a part of the essential duties for member, provider, and community visits.
WHAT YOU'LL BRING
- Active California RN or LVN license without restriction and 3 years preferred experience in case management, discharge planning, or equivalent combination of education and experience.
- BSN, MSN or related degree may be considered in lieu of relevant work experience
- Experience with public health nursing and/or Care Management with safety net populations preferred
- Experience with NCQA, Complex Care Management requirements
- CCM certification preferred
- Excellent oral and written communication skills
- Knowledge of San Francisco County community resources, Medicare and Medi-Cal
- Strong medical knowledge of common medical conditions, including but not limited to: Diabetes, Hypertension, End-Stage Renal Disease (ESRD), Chronic Obstructive Pulmonary Disease (COPD), Asthma, Liver Disease, Hep C and chronic wounds
- Experience working with individuals with multiple diagnoses who may have multiple barriers (i.e. mental illness, substance use, access to care, and chronic medical conditions)
- Flexibility managing multiple workflows and program requirements
- Time management and prioritization skills are vital
- Working knowledge and use of Trauma Informed, Harm Reduction and Person Centered language and principles
- Must be knowledgeable of Case Management/Care Management practices to meet needs of medically complex as well as those with complex psychosocial needs
- Knowledge of Health Plan/ Integrated Delivery system models of Case Management and Care Coordination best practice.
- Medical code knowledge is helpful, but not required
- Population-based perspective on care delivery and access disparities for vulnerable patient populations
- Ability to conduct home and other community-based visits
- Experience educating members, their families and medical providers on post-discharge needs.
- Experience with coordination of care for members requiring services from community agencies, the department of public health, and Medi-Cal carve-out and waiver programs preferred.
- Ability to collaborate with team members on cross-departmental improvement efforts, quality improvement projects, and optimization of cost management, member satisfaction improvement, and projects centered on decreasing avoidable ER and inpatient use
- Attention to detail is vital as is maintaining focus and meeting deadlines.
- Ability to motivate self and others.
- Ability to work with socially and ethnically diverse populations
- Proficient use of Microsoft applications such as Word, Excel, Outlook and Access; ability to use mobile technology
- Bilingual in Cantonese or Spanish preferred but not required
- Because this position may require member home visits, the incumbent must successfully complete a sex offender registry screen
Established in 1997, San Francisco Health Plan (SFHP) is a an award winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco county. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 145,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. SFHP was designed by and for the residents it serves, and takes great pride in its ability to accommodate a diverse population that includes young adults, seniors, and people with disabilities.
San Francisco Health Plan is an Equal Opportunity Employer (EOE) M/F/D/V.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.