RN Case Manager- ECM Job at JWCH Institute in Los Angeles

Company Mission Statement:
The Mission of JWCH Institute is to improve the health status and well-being of under-served segments of the population of Los Angeles Area through the direct provision or coordination of health care, health education, services, and research. The mission is being accomplished through a variety of programs and activities, such as: medical outreach and referrals for medical care, HIV services and drug treatment; health education; psychosocial assessment and intervention; primary medical care; family planning services; and research.

Position Purpose:

Under the direction of the ECM Program Director and the ECM Clinical Director, the Registered Nurse will serve as the RN Clinical Case Manager for the ECM program. In this role, the RN will collaborate with all parties involved in the patient’s care, including the interdisciplinary team, lead care manager, patient, family, and significant others to ensure comprehensive intervention and care coordination for patients managing multiple chronic conditions or those experiencing homelessness.

The RN Clinical Case Manager will regularly update and modify care plans based on reassessment findings and evolving patient needs, coordinating these adjustments with the primary care provider (PCP) and Lead Care Coordinators. Additionally, the RN will review and sign off on care plans prepared by other Care Managers once they are finalized and ready for submission to the Health Plans.

Principal Responsibilities:

1. Provide clinical oversight to Lead Care Managers, assisting them in coordinating patient care, including making referrals, offering educational resources, and supporting patients in achieving health goals.
2. Ensure compliance by documenting clinical encounters in Next-Gen according to Health Plan guidelines.
3. Deliver Clinical Case Management (CM) services to high-risk, low-income populations, coordinating care for patients with complex medical and psycho-social needs.
4. Conduct comprehensive assessments in collaboration with the PCP and Lead Care Manager to evaluate medical and psycho-social conditions.
5. Offer patient education based on identified needs, utilizing available resources, and communicating these needs to the interdisciplinary team.
6. Develop and update Individual Plans of Care (IPC) in partnership with the patient and Lead Care Manager, ensuring plans are medically appropriate and revised as needed.
7. Facilitate case conferences with the PCP, LCSWs, and Lead Care Managers, adjusting the level of care based on patient acuity.
8. Maintain detailed documentation of patient progress and care interventions, ensuring ongoing assessment of medical goals.
9. Collaborate with a multi-disciplinary team, integrating services from medical, behavioral health, and other healthcare providers.
10. Participate in clinical supervision sessions and team case conferences to discuss patient care and improve outcomes.
11. Lead orientation sessions for new ECM staff on health and medical protocols, and actively engage in staff meetings and continuous training programs.
12. Coordinate patient referrals and conduct follow-up assessments based on clinical findings and required interventions.
13. Engage in quality improvement activities in alignment with contract and agency policies to enhance service delivery.
14. Perform other related duties as assigned.

Requirements:

1. Valid Registered Nurse (RN) license in good standing with the State of California.
2. Minimum of two years of experience in case management, care coordination, or a related field.
3. Strong verbal and written communication skills.
4. Proficiency in Electronic Health Records (preferably Next-Gen, though training on other systems will be provided), as well as MS Word and MS Excel.
5. Bilingual in English and Spanish preferred/
6. Familiarity and experience with behavior change models.
7. Knowledge of chronic disease management and best practices in care coordination.
8. Demonstrated ability to provide compassionate care to vulnerable populations, such as those experiencing homelessness or managing multiple chronic conditions.
9. Ability to respond effectively to patient crises, including medical emergencies or behavioral health challenges.
10. Experience working in interdisciplinary teams, collaborating with physicians, social workers, and other healthcare professionals.
11. Ability to manage a caseload efficiently, prioritize tasks, and meet deadlines in a fast-paced environment.
12. Sensitivity and experience working with diverse populations, including individuals from various socioeconomic backgrounds.

Wesley Health Centers JWCH Institute is an Equal Opportunity Employer!