High Risk Care Manager, Senior Health (Remote - Texas)

Overview:

One Medical is looking for nurses with care management/ case management backgrounds to join our rapidly growing Care Management Team. In this remote role, you will follow high risk One Medical Senior patients as they transition across the care continuum and throughout their first 30 days after discharge to home. 

Essential Duties and Responsibilities

• Provide transitional case management to a panel of 50 complex high-risk patients per month by working with patients, families, providers, and healthcare facilities to improve clinical outcomes and help reduce readmissions to acute care settings.
• Interact with internal and external care team members to provide coordination for patients needing short-term case management and safety interventions after discharge from acute care facilities, post-acute care facilities, or emergency departments.
• Serve as the primary liaison between partner providers and the patient's primary care team during time of transition, engaging in care planning, medication reconciliation, pre- and post-discharge planning, and safe handoffs of care. Manage assigned patients with the purpose of helping them be more effective at managing their own care, understand their medical conditions and medications, navigate the healthcare system and utilize resources appropriately. 
• Create a patient centered-care plan for each patient in partnership with High Risk Medical Directors, and consistently document planned interventions and patient self-management strategies. Ensure care plans are clearly communicated to the practice care teams for continuity of care.
• Address and resolve post-discharge barriers and potential readmission factors including home health, durable medical equipment, and social determinants of health.
• Communicate significant clinical information regarding assigned patients to other members of the healthcare team and especially to the patient's PCP.
• Attend case conferences and team huddles as appropriate with regards to patient collaboration
• Effectively navigate health insurance policies and guidelines regarding acute and long term care.  Develop a positive working relationship with sponsor care management staff. 

Build strong relationships with health systems and facilities, including facilitating coordination and communication channels.

Candidate Attributes:

• Must be a goal-oriented, high energy, passionate leader who models organizational values and is able to set the tone for a positive work culture.
• Must demonstrate outstanding clinical aptitude, using sound judgment in caring for patient needs.
• Must demonstrate ability to use core coaching and educational techniques, including motivational interviewing and patient-centered communication to activate and empower patients and families.
• Must demonstrate excellent interpersonal communication skills with a variety of audiences via telephone, in person, and electronic means including exceptional listening skills, ability to use appropriate language and demonstrated writing skills. Comfortable engaging openly with hospital leaders/ admitting physicians at partner facilities. 
• Must demonstrate ability to think outside of standard operational structure.
• Must be creative, flexible, focused on continuous-improvement and comfortable with ambiguity and change. 

Qualifications: 

• Willingness to work 8am-5pm Central Time and have some knowledge of the greater Houston healthcare landscape and geography.
• Licensed RN in Texas required with willingness to obtain licenses in other states
• Comprehensive knowledge of utilization management/ care management principles
• 3+ years of nursing experience
• 2+ years of care coordination experience, ideally spent interfacing with hospitals/ SNF and long term care facilities.
• Knowledge of the local health care community preferred.

About Iora Health

Iora Health is restoring humanity to healthcare by building a simple yet radically-different primary care model from scratch: we know each of our patients as true individuals, and proactively provide the unique combination of care, support, and inspiration they need to live their best life.

The Iora Health (www.iorahealth.com) model of health care changes everything – payment, staffing, processes, IT systems, and culture. We have no status quo to defend, no arcane rules we must follow. We are a fast-paced, fresh-thinking, high-growth company building a better model of health care delivery.

Iora Health patients enjoy the benefits of improved access to care, non-office based encounters (e.g. phone, video chat, email, walking groups, etc.), an accessible and transparent medical record, and robust educational offerings. Iora Health practices offer smaller panel sizes, closer relationships between patients and care teams and the opportunity to lead systemic change in health care delivery while working with a true team.