RN Chronic Care Manager, Population Health​/Value Care Culver

Position: RN Chronic Care Manager, Population Health/Value Based Care- Full Time, Days (Culver City)
The CRC Chronic Care Manager for Population Health and Value Based Care will facilitate coordination, communication, and collaboration with patients/members, providers, ancillary services, and leadership to achieve goals and maximize patient/member outcomes through an innovative whole person chronic care strategy by working with CRC, Hospitals, MSOs and IPAs. Best practice focus will be placed on the provision of care in the ambulatory care settings, efficient patient/member management through chronic care management and leadership escalation to ensure appropriate use, level of care and timeliness of services.

The Chronic Care Manager for Population Health and Value Based Care will promote the vision and be responsible for the implementation of these strategic objectives.

* The Chronic Care Nurse Care Manager implements programs within assigned areas. Position requirements includes a thorough knowledge of the organization's policies, procedures, workflow, monitoring and oversight tools, employee relations, company goals and vision. Chronic Care Nurse Care Manager must have strong leadership skills with the ability to influence and motivate interdisciplinary team members. Successful Chronic Care Nurse Care Manager will have persistence to challenge and move patients through the continuum without losing focus of the quality and cost of care

* The Chronic Care Nurse Care Manager sees patient and system challenges and obstacles as opportunities for innovation and success. This person possesses the ability to work independently, remotely and has a passion to create a lasting impact on patient's lives and health.

* Chronic Care Nurse Care Manager must have the ability to prioritize competing demands and promote a multidisciplinary team approach with strong problem-solving skills and attention to detail. Is responsible for consistent operational compliance and reporting to satisfy and exceed state, federal and accrediting agency standards.

* Must have experience implementing new programs, which includes but is not limited to those which support the management of patients with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care to prevent re-admission. The Chronic Care Nurse Care Manager ensures that Members' medical, environmental, and psychosocial needs are optimized through the continuum of care.

* Chronic Care Nurse Care Manager participates as needed in physician/hospitalist, daily and weekly operational, department meetings, JOCs and MSO daily rounds meetings as delegated by the Medical Director or Population Health and Care Management Director. Chronic Care Nurse Care Manager assists Medical Director and Population Health and Care Management Director with the daily clinical operations, compliance, and oversight of programs.

Participates as the liaison and contact for operational teams members and is responsible for communication, coordination and monitoring of organization-wide chronic care initiatives and operations related to in/outpatient case management programs.

* Plans, develops, implements, evaluates, refines care management/social work intervention, and provide coaching and guidance to the Clinical Management staff for effective and efficient operation of social services, community care and other chronic care management programs.

* Participates in the daily management of care and disease management functions, daily in-patient rounds, MSO in/out-patient high intensity rounds, home visits, social workers, palliative, hospice and home medication therapy management programs. Interfaces with CRC and MSO Medical Directors and attends / participates in Interdisciplinary Rounds.

* Works collaboratively with Medical Director and Population Health and Care Management Director to ensure compliance is maintained, identifies specialist issues, reviews re-admissions and avoidable admissions.

* Coordinates provisions for complex ambulatory care (disease management, social services, behavioral health, palliative/hospice, health education, community resources, etc.)

* Demonstrates consideration for the needs, clinical and financial, of the patients, payers, CRC clinical and partner MSO | IPA team members. Implement and support a culture of continuous quality improvement, regulatory and accreditation code of professional conduct, and the federal and state regulations on confidentiality, as well as all policies and procedures Prospect Medical Holdings Hospitals.

* Coordinates the collaboration with patient's family and physicians for seamless coordination of care and services. Monitors and evaluates effectiveness of the chronic and end of life care management plan(s) and modifies as necessary to meet health plans and national standards (i.e., NCQA and DMHC requirements) for turn-around-time for assessments, care plans and IDTs.

* Identifies and implements Initial Care Plan (ICP) by conditions identified in CCSPIP, patient assessment, medical records,…