Nurse Care Manager, Care@Home - Full Time

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

Care@Home is a home-based primary care program that provides health care services in the comfort and convenience of the patient's home. It's like an old-fashioned house-call for patients who are eligible to join. The program provides primary medical care, social support, and help with nutrition and medications.

The Field Based Nurse Care Manager will provide high quality, evidenced based in-home patient care to complex and high-risk patients with the primary goal and objective of providing best-in-class patient care, reducing avoidable hospitalizations, and decreasing unnecessary emergency department utilization. As a member of the program care team, the Nurse Care Manager, in collaboration with a supervising NP, PA and/or physician, will be responsible for delivering effective clinical services in the home. The RN will address all aspects of care, both chronic and acute primary care complaints, and be able to determine medical urgency and triage as appropriate. Compliance with all HIPAA regulations and maintain security of protected health information (PHI) is required.

Job Responsibilities/Duties

• Represent Care@Home as the initial face-to-face contact with new patients.
• Build rapport with patient and caregiver and/or family while explaining the program details.
• Gain patient commitment to participate in Care@Home.
• Perform medication review, medical triage and add patient information into EMR.
• Conduct face-to-face and telemedicine medical visits with patients for routine visits, acute illness, and post-acute discharge for patients with complex medical conditions.
• Assess patient's condition during every visit and chart observations.
• Perform evaluation tasks, including vital signs and medication review.
• Administer medication as prescribed by the patient's Physician, PA or NP.
• Dress or redress open wounds and assess progress of healing.
• Educate patients and their families on proper health care strategies and procedures.
• Coordinate with Nurse Practitioners, Physicians, Physician Assistants, Dietitians, Social Workers, and anyone else involved in the patient's care plan.
• Provide palliative care as needed to keep the patient comfortable.
• Make recommendations for devices or tools that might improve the patient's quality of life.
• Listen to the patient and respond to concerns or requests.
• Must be comfortable performing in-home procedures, such as, but not limited to: wound care, phlebotomy, IV medication, catheter insertion and removal.
• Determines effectiveness of the plan of care and reassesses and modifies the plan of care as necessary to achieve medical and health goals.
• Provide education on health conditions, medications, illness trajectory, and treatment options to patients, families, caregivers, and providers.
• Facilitate goals of care discussions with patients and facilitate the completion of advance.
• Perform timely and accurate documentation of patients' medical information and all activity related to patient care in electronic medical record system. Prep the chart, complete full and appropriate documentation to reflect the services provided in accordance with company policies and procedures.
• Communicate, by phone, in person, in writing, or electronically, with PCPs and Specialists in order to provide comprehensive care or to make referrals, as necessary. Consult with supervising NP, PA, or Physician as appropriate.
• Participate in On-Call program which may include after-hours, weekend and holiday calls and visitations.
• Provide feedback for program development. Participate in collaborative multidisciplinary team meetings to optimize clinical integration, efficiency, and effectiveness of service delivery as required.

Minimum Education: Current, unrestricted RN CA state license.

Minimum Experience: Two (2+) years of experience working as a Registered Nurse in an in-home program. Advanced knowledge of and experience with symptom management. Advanced knowledge of and experience with symptom management. Experience dealing with a complex set of patients with a relatively high level of acuity. Ability to function in an interdisciplinary team is essential. Access to reliable transportation that will facilitate travel to multiple patient homes per day. Excellent communication and time management skills. Ability to establish therapeutic relationships with patients and families. Basic computer literacy and experience with EHR information system, word processing and email. Effective written and verbal communication skills. Demonstrated ability to be self-directed, and motivated. Ability to maintain courteous professional attitude when working with internal and external customers. Ability to maintain member confidence and protect operations by keeping patient information confidential in compliance with HIPAA requirements. Compassionate and friendly demeanor.

Req. Certification/Licensure: Current, unrestricted RN CA state license and current driver's license.

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

• Company 401K
• Medical, dental, vision insurance
• Paid time-off
• Life insurance

To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www1.eeoc.gov/employers/poster.cfm

Keywords: RN, Patient Care, Home-based Care, Triage, EMR, Telemedicine, Palliative Care, Care Coordination