The Care Coordination Nurse conducts telephonic calls to assist with care coordination and health education for identified health plan members. The nurse will assure that members have access to quality, cost-effective health care and assists in the assessment, coordination, teaching aimed at self-management, and monitoring activities to facilitate member care. The nurse will collaborate and facilitate care with medical service providers including but not limited to physicians, home health providers, medical equipment vendors, and community resources.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Identifies potential candidates effectively by utilizing various CCHP data sources, such as daily inpatient census, internal data, self-referrals, provider referrals, and utilization management staff.
• Conduct member outreach in response to referrals to assist with member issues or concerns.
• Assess and manage member needs such as complex medical, psychosocial, cognitive and functional conditions.
• Identify early risk factors and conduct ongoing phone assessments when necessary.
• Assist with member Health Risk Assessment (HRA) surveys to administer and contact as needed.
• Review members’ HRA survey responses for both Commercial and the Senior Select (Special Needs Plan) population.
• Develop a comprehensive care plan with appropriate interventions consistent with CCHP policy guidelines and Medicare/Medicaid requirements within the care management system.
• Gather input from the member and/or responsible parties in the development of the care plan.
• Modifies the plan of care through monitoring and re-evaluation to accommodate changes in treatment or progress for assigned members.
• Document all activities in the CCHP’s care management system to allow for continuity of care.
• Performs post discharge follow up, case management, and disease management duties through promoting healthy lifestyles, closing gaps in care, reducing unnecessary ER utilization and hospital readmissions.
• Provide members with appropriate education to enhance their knowledge related to health or lifestyle management.
• Identifies for medically complex members and consult with others of the interdisciplinary team.
• Work collaboratively with others of the interdisciplinary team in assessing, planning, and providing services to members.
• Assist in coordinating communication between doctor’s office, clinics, hospitals, member/families, home health agencies, vendors, and CCHP staff.
• Utilizes evidence-based guidelines such as Interqual Guidelines and other tools such as HealthWise.
• Maintain a caseload panel through prompt identification and response to cases appropriate for level of care changes including but not limited to discharge or transfer activities.
• Monitors & reports outcomes of the member weekly/ monthly as requested.
• Participates in team meetings.
• Accepts and performs other duties as assigned.

QUALIFICATIONS

• Current California RN or LVN license
• Associate degree in Nursing or above
• Excellent verbal and written communication skills
• Bilingual in English and Chinese
• Ability to set and change priorities quickly or as the situation warrants
• Able to work independently and as team player
• Proficiency in Word and Excel
• Ability to maintain high volume workload without compromising quality
• Minimum two years acute inpatient care experienced preferred