Care Manager

Overview CareConnectMD DCE is a specialized High Needs Direct Contracting Entity (DCE) geared towards medically complex Medicare beneficiaries who reside in nursing homes, assisted living facilities, board and care facilities and at home. The comprehensive program provides a care model that is designed to meet the unique health care needs of medically complex Medicare beneficiaries. Under this value-based care model, CareConnectMD DCE will deliver care coordination services in close collaboration with primary care physicians, specialists, and advanced practice professionals in California, Georgia, Ohio, Indiana, Texas, as well as other expansion locations. Learn more at www.careconnectmd.com Position Description As the Care Manager RN or LVN for CCMD, you'll be responsible for utilizing your clinical expertise as well as organizational and communication skills in dealing with medically complex patients wherever they reside. Working in collaboration with a comprehensive care team composed of physicians, advanced care practitioners and care coordinators, you will assess the needs and condition of patients, coordinate care with nursing facilities, clinicians and community-based providers and develop and implement a plan of care. CCMD DCE provides care to our most frail population with significant medical issues and is committed to providing comprehensive care for this population that benefits body, mind and overall quality of life. Key Duties and Responsibilities This position is responsible for the assessment, care planning and coordination of care and evaluation of services for Medicare Beneficiaries aligned with the CareConnectMD DCE. This includes ongoing monitoring of an appropriate person-centered care plan, education and care coordination. Maintains a caseload of patients, monitoring of needs and facilitating transition of care. Serves as the primary point of contact throughout the treatment episode at all levels of care. Coordinates with the interdisciplinary team of providers, vendors, facilities, discharge planners, nurses, social workers, care coordinators, caregivers to effectively manage care plans and transition of care settings. Communicates regularly with the patient's primary care provider and other clinicians. Collaborates with family members to optimize outcomes to include timely identification/evaluation of current patient needs (care settings, post-hospitalization needs, caregiving needs) and providing additional resources and referrals. Seeks consultation with others when needed, such as social services, behavioral health, and durable power of attorney. Participates in inpatient/family meetings, respecting and promoting patient choice and documents informed decision making. Utilizes knowledge of psycho-social and physical factors that may affect patient outcomes. May include educating and mediating client family members in an effort to advocate for client needs. Maintains timely, complete and accurate documentation in compliance with regulatory policies and procedures. Provides consultation to PCP/Providers as indicted with patient's consent. Collaborates with nursing facility staff to ensure that patient is receiving care that is appropriate and consistent with medical necessity. Tracks patients' utilization of skilled Part A and Part B services in a nursing facility to include documentation of medical necessity and continued stay review When a patient is in the emergency room or hospital, coordinate care with attending staff and collaborate with staff to ensure the optimal transition of care to next level of care and to the patient's residence. Provides oversight of medication administration for the client. Administers caregiver education and training: orientation, as needed, and annually. Acts as an effective liaison to onsite facility (hospital, skilled nursing, assisted living, memory care, and mental health) to ensure continuity and congruity of services in accordance with the clients Plan of Care. May include visiting clients in the aforementioned settings and evaluating current quality of care. This position requires local travel and on call. Education and Experience Licensed Nurse (LVN or RN) At least 2 years of experience in case management for value-based care (health plan, delegated provider group, ACO, etc.) Experience in working in a post-acute setting is a plus Experience in working with frail, medically complex patients Works with Microsoft 365 (Microsoft word, excel, powerpoint, Teams meetings, calendaring) Well versed in navigating and documenting electronic medical records Current/Valid state driver's license and insurance Benefits and Salary: This position reports directly to Senior Medical Officer Allowances for mileage Employer provided laptop and cell phone Vacation/Holidays/PTO Location: Combined in office (Costa Mesa, CA) and remote work Monday to Friday Essential Skills and Abilities Thrives in an unstructured, start-up environment. Self-starter that can work independently and collaboratively, prioritize tasks and has initiative and excitement to take on unfamiliar tasks Working knowledge of company policies, procedures, and operations Excellent composition, grammar, and business language skills Excellent communication and interpersonal skills with the ability to effectively communicate with all levels of management Creative, flexible, well organized, resourceful and detail-oriented Excellent judgment in handling confidential and sensitive information Ability to work independently, set priorities and handle multiple tasks with a high level of efficiency Ability to establish and maintain cooperative working relationships with others Ability to work across locations and time zones Exceptional critical thinker Core Competencies Customer focus Manages ambiguity Collaborates Drives results Team player To ensure the health and safety of our workforce while doing our part to protect those around us, CareConnectMD is requiring proof of full COVID vaccination for employees as a condition of employment, subject to legally recognized accommodations.