Summary

SUMMARY: Responsible for providing comprehensive case management services to clients identified with complex health conditions and social challenges that are at risk for health status decline. The goals and focus of these service efforts are to provide timely delivery of intensive case management services across multiple domains, including the community, ambulatory and specialty care settings, to prevent further health deterioration and reduce the need for more costly services such as acute care hospitalization and to develop self-management skills that improve his or her long-term health status. Incumbent performs all duties and responsibilities in accordance with the values of the organization. Performs related duties as required.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: Following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

1. Acts as a liaison with primary care providers for identified groups of hospitalized clients. Maintains close working relationships with identified community-based providers. Visits clients/potential clients in both hospital and community settings, including private homes. Provides own transportation to community based visits.

2. At times, supervises Student Nursing Interns and/or Medical Assistants.

3. Communicates with physicians and multidisciplinary health team members to provide continuity of care, supporting and maintaining the multidisciplinary team approach to ensure effective resource utilization; documents as needed in the patient medical record.

4. Interprets and explains procedures, regimens, and services to patients and families; teaches patients and family member's health care and disease prevention techniques.

5. Participates in promoting a healthful, safe, and therapeutic environment for patients and families, set up and controls the environment essential for infection control.

6. Monitors care provided making suggestions to achieve optimal outcomes, based on evidence base practice. Participates in outcome data monitoring and audits as needed.

7. Obtains signed consent form for client participation and for release of information from client, and initiates Care Plan. In conjunction with the interdisciplinary team, teaches, supervises, and counsels the client and identified support system regarding the care plan. Delivers delegates and/or supervises individual client interventions, including care coordination and evaluation of outcomes.

8. Promote health care along the continuum of services, decreasing care fragmentation through care coordination with other community providers, enhancing the client's quality of life by improving access to services and preventing inappropriate institutionalization and providing cost-effective service planning.

9. Provides disease management education and coaching, focusing on individual client self-management principles. This includes medication reconciliation, development of a person health record, preparing for provider visits and community resource. Makes appropriate recording of interventions and client progress, and reports patient status to CTP or CCM team regularly.

10. Reassesses the client's condition when changes occur and revises the care plan as appropriate. Coordinates and arranges for needed services with appropriate local resources. Serves as patient advocate to secure services and financial benefits.

11. Responsible for direct service provision including enrollment into CTP or CCM, care coordination and evaluation of care plan.

12. Serves as a mentor and educator to the other members of the Alameda County Health Center healthcare team assisting with care coordination, training, and quality improvement activities.

13. Utilizes concepts of assessment, education, health coaching and provide patient centered services. Organizes, prioritizes and completes activities and assignments in an efficient manner.

14. Utilizes reports and patient lists within the EHR to identify, screen and enroll eligible patients.

15. Assesses potential clients using the designated tools and initiates hospital-based coaching activities/interventions as appropriate and in coordination with hospital staff.

MINIMUM QUALIFICATIONS:
Education: Bachelor's Degree in Nursing or related field, Master's degree in Nursing or health related field preferred.

Minimum Experience: One to three years acute care experience a plus. Varied clinical experience or experience in case management/community health a plus.

Preferred Licenses/Certification: Public Health Nurse, Case Management, Home Health.

Required Licenses/Certifications: BLS - Basic Life Support Certification - issued by AHA-American Heart Association.

Required Licenses/Certifications: Valid California Driver's License.

Required Licenses/Certifications: Valid license to practice as a Registered Nurse in the State of California.