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Seen Health · 1 month ago

RN Care Management

Alhambra, CA

Full-time

Onsite

Mid, Senior Level

$120K/yr - $145K/yr

5+ years exp

Seen Health is a culturally-focused, technology-enabled healthcare organization that aims to revolutionize senior care through the PACE model. The RN Care Manager plays a critical role in ensuring comprehensive and coordinated care for frail and elderly participants, focusing on care coordination, assessments, care planning, and promoting optimal health outcomes.

Health CareMedical

Responsibilities

Performs duties and responsibilities maintaining compliance with regulatory requirements, Seen Health policies and procedures and quality improvement initiatives

Collaborates with Medical Director, primary care providers, clinic manager, and the interdisciplinary team (IDT) to coordinate care across different care settings, ensuring that IDT maintains oversight of participant care and to ensure that participants receive necessary services (medical, social, supportive)

Facilitates access to community care. Performs participant advocacy and maintains daily communication with facility based providers. Facilitates informed decision-making, ensuring that IDT receives timely notifications regarding the health status of participants

Collaborates with IDT to coordinate timely discharge planning, ensuring that participants are discharged to home as soon as possible. Arrange follow-up care after hospitalizations or changes in health status, including PCP f/u appointments

Provides education to participants, caregivers and family members regarding care transitions, upholding standards for informed consent

Provides end of life support, as needed, managing symptoms for patients receiving palliative care and providing comfort measures and emotional support to participants and families

Coordinates timely Home Health nursing interventions based on primary care provider (PCP) orders. Requests home health records from subcontracted providers and uploads records of completed services in the participants’ electronic health record. Communicates service outcomes to IDT, ensuring that the PCP and IDT maintain oversight of participant care

Performs authorized nursing and care management services in participant home, as needed e.g. wound care, vaccine or medication administration, etc

Completes Utilization Management activities, including but not limited to tracking utilization of hospital admissions, emergency room visits, and specialist consultations. Identify patterns of overuse or underuse of services and take corrective actions as needed

Monitor health outcomes and the effectiveness of care plans to ensure that services provided are leading to desired health improvements. Use data and analytics to identify opportunities for improving care delivery and reducing unnecessary utilization

Conducts home care assessments and creates home care orders with tasks for ADLs and IADLs. Obtains and ensures that home care order is co-signed by Primary Care Provider prior to delegating service coordination to the Home Care Coordinator, LVN

Updates care plans with home care intervention plan and progress notes. Documents service outcomes in participant electronic medical record. Collaborates with Home Care, LVN ensuring that home care records from subcontracted agencies are requested and uploaded to the participants’ electronic medical record in a timely manner

Maintains complete medical records, with thorough documentation and maintains confidentiality of participant information in Electronic Health Record system