If you are you searching for a rewarding job opportunity within a community healthcare system driven by its mission of providing excellent health care to its patients, then, East Valley Community Health Center has an exciting job opportunity for you!
Through our five health centers in East San Gabriel and Pomona we have been providing healthcare to under-served communities for the past 50 years. Our patients benefit from comprehensive services including medical, dental, vision and mental health.
The Care Manager provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across settings and helps patient/families understand health care options. Manages a caseload of approximately 200 complex patients.
The RN Care Manager works collaboratively with the patient, family members and the care team to provide services designed to promote health, prevent illness, and achieve optimal health outcomes. The Care Manager provides targeted interventions to avoid hospitalization and emergency room visits and coordinates care across settings.
Major Position Responsibilities and Functions:
- Identifies targeted high-risk population within practice site(s), per PCP/Care Team referral, risk stratification, and patient lists.
- Assesses over time the healthcare, educational and psychosocial needs of the patient/family. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.
- Collaborates with PCP/Care Team, patient, family members and other continuum of care settings. Responsible for developing a comprehensive individualized care plan and targeted interventions. Continually monitors patient care plan goals and achievements, and revises the care plan in collaboration with the patient and care team.
- Provides self-management support with focus on empowering the patient/family to build capacity of self-care.
- Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.
- Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
- Coordinates patient care through ongoing collaboration with PCP, patient/family, and other members of the health care team. Fosters a team approach and includes patient/family as active members of the team. Takes the lead in ensuring continuity of care, which extends beyond the practice boundaries. Serves as liaison to acute care hospitals, specialists, and post-acute care services.
- Provides follow-up with patient/family when patient transitions from one setting to another. Completes timely post-hospital follow-up: Medication reconciliation, PCP or specialist follow-up appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.
- Works with care teams and leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance the Patient Centered Medical Home model of care.
- Manages a caseload of approximately 200 complex patients.
- Performs procedures that fall outside of the Licensed Vocational Nurses scope of practice (i.e. vivitrol injections, triage assessments, etc…)
- Other assigned duties as directed.
POSITION REQUIREMENTS AND QUALIFICATIONS:
- Completion of accredited Registered Nurse training program, and current license as an RN in the State of California.
- Two years of experience with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical, within the past five years.
- Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education.
- Critical thinking skills and ability to analyze complex data sets. Ability to manage complex clinical issues utilizing assessment skills and protocols.
- Excellent assessment and triage skills. Ability to implement evidence based interventions and protocols for chronic conditions.
- Demonstrate excellent communication-both verbal and written.
- General computer knowledge and capability to use computers.
- Demonstrate customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, religious and cultural ideals.
- Demonstrate ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.
- Bilingual in English and Spanish, preferred.
East Valley offers a competitive salary, paid holidays, PTO, and 403b retirement plan. East Valley matches the first 6% and you are fully vested immediately! You will also enjoy work-life balance with paid time off and paid holidays throughout the year (including your birthday!)
Please apply to this position with your current resume.
Principals only. Recruiters, please do not contact this job posting.
EOE is the Law. It is the stated policy of EVCHC to conform to all the laws, statutes, and regulations concerning equal employment opportunities and affirmative action. We strongly encourage women, minorities, individuals with disabilities and veterans to apply to all of our job openings. We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, gender identity, or national origin, age, disability status, Genetic Information & Testing, Family & Medical Leave, protected veteran status, or any other characteristic protected by law. We prohibit Retaliation against individuals who bring forth any complaint, orally or in writing, to the employer or the government, or against any individuals who assist or participate in the investigation of any complaint or otherwise oppose discrimination.
East Valley Community Health CenterEast Valley Community Health Center is a Federally Qualified Health Center (FQHC) serving the East San Gabriel and Pomona valleys for the past 50 years. We are a mission-driven organization providing quality and accessible health care to our communities through our multi-practice facilities and excellent healthcare professionals. Our mission is to provide access to excellent health care while engaging and empowering our patients, employees and partners to improve their well-being and the health of our communities.