|
Search Jobvertise Jobs
| |
Jobvertise
|
Healthcare Transitions Coach - (Case Manager / Public Health) -
Location: US-CA-Long Beach
Email this job to a friend
Report this Job
Job Title: Healthcare Transitions Coach I Location: Remote/PST Shift Duration: 3 Months (extendable) Job Overview: Position will be remote. There are no specific work locations but the position will cover cases primarily in Los Angeles and San Diego so the candidate needs to work during PST hours. Must have Healthcare Case Management Experience. No Licensure required to qualify for the role (prefer RN or LVN) Required Experience: Minimum1-2 years Medical Case Management experience. Minimum 1-2 years Public Health experience. Knowledge or experience using the Care Transitions Intervention or similar model Background in discharge planning and home health Required Licensure/Certification: Active, unrestricted State Registered Nursing license in good standing preferred Summary: Responsible for safely and effectively transitioning members from acute or inpatient care to lower levels of care and/or home in a cost efficient manner. Provides assessment, planning, implementation, coordination, monitoring, and evaluation of services for members as they transition care and follows them for 30 days post discharge. Conducts an onsite or telephonic hospital discharge visit and post-discharge visit to assure continuity of care and prevent unnecessary readmissions. Refers complex cases to case management as appropriate based on consultation with the Interdisciplinary Team. Essential Functions: Identifies, assesses and manages members during care transitions per established criteria. Coordinates transition of care between inpatient and other settings with the practitioner, Healthcare Services (HCS) staff, community based agencies, social workers, hospital/nursing facility discharge planner, and/or other providers as required. Coordinates necessary services with participating ancillary service providers and public agencies as appropriate to ensure quality, cost effective care and reduced readmissions for the member Conduct one discharge planning hospital visit or telephone call with the member or member's designee at assigned facilities prior to discharge and one home visit or telephone call to member after discharge to: o Discuss the Transition of Care Program o Identify staff and roles as they differ from the facility staff (all staff must wear company identification for all facility and or home visits) o Introduce Personal Health Record (PHR) o Review Discharge Plan and member's understanding of the plan o Evaluate current medications via the medical record or advise the member to request that facility staff review the medication list o Discuss the importance of understanding prescribed medications and having a system in place to ensure adherence to the regimen o Discuss the Medication Record o Facilitate appointment with either the Primary Care Physician/Practitioner or treating specialist within 5 days of discharge o Provide information and contact numbers for resources (transportation, Nurse Advice Line (NAL), Care Coordination/Case Management, Behavioral health) o Discuss emergency plan o Conducts 3-4 additional telephone calls to members over a 30 day period to complete the Transition of Care protocol. Conducts any additional calls needed to facilitate TOC. - Develops a plan of care consistent with sound medical, behavioral health, chemical dependency and financial management. Includes assessment of health needs, individualized care plans and/or service plans, implementation, monitoring and evaluation of case outcomes.
- Consults with interdisciplinary care team to create care plan as needed and facilitate access to needed care and services
- Arranges for health care services within the scope of available benefits.
- Documents medical management within the electronic medical record system. Documentation includes assessments, service plans and/or care plans and updates, contacts and planned tasks.
- Reviews and updates care plans for continuity of care and facilitates plan modifications including barriers to goals and interventions for members being coached through the transition of care from the inpatient and or skilled nursing facility.
- Maintains active caseload and conducts expected face to face or telephonic visits consistent with Healthcare standards.
- Maintains department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores.
- Attends meetings related to care coordination and HCS Department topics.
- Provides coverage for other staff as needed.
- Other Duties as assigned. Complies with workplace safety standards.
Knowledge/Skills/Abilities: Exceptional telephone manners and patience in handling a variety of callers. Must have a courteous manner and positive attitude when interacting with employees and customers. Demonstrated adaptability and flexibility to changes and response to new ideas and approaches. Demonstrates professionalism at all times. Ability to independently use resources to solve problems. Effective and culturally sensitive communication skills with individuals and families from diverse ethnic and cultural backgrounds Bilingual based on community need Ability to motivate members to be active participants in their health Knowledge of applicable state, federal and third party regulations and standards (Medicare, Medicaid, Copes, MPC, SSI). Comfortable working with Aged, Blind, Disabled, and Severely Mentally Ill populations with varied economic and educational circumstances Maintain member respect and dignity while displaying maturity, empathy, ethics, confidentiality and professionalism Provide health education and advocacy to members and their families Must have a high regard for confidential information Ability to work in a fast paced environment Works independently and as part of a team. Computer and Microsoft Office experience. Accurate data entry at 40 WPM minimum. Skilled at identification and elimination of barriers to receiving services Broad knowledge of area community resources/agencies Ability to develop and execute plans of care and prepare reports as needed or requested Required Education: - Bachelor's Degree preferred in area of preferred education or LVN course of study with license
The Structures Company
|
