Community Health Innovations (CHI), a new subsidiary of Community Hospital of the Monterey Peninsula, oversees integrative population management strategies, a healthcare approach that integrates and coordinates care, focusing on early detection, disease management, and evidenced-based best practices. CHI will lead in the development of the patient-centered medical home, an approach to patient care, within a primary care doctor's office, that emphasizes wellness and prevention, improved health outcomes; a team approach to care for patients with the most complex needs. |
The Care manager oversees care management and coordination of health care services for assigned patients in the primary care practice. The primary responsibilities of the Care Manager RN is to identify patients who will benefit from care management using specific criteria, screen each patient for individual needs and barriers to optimum wellness with standardized tools, track, monitor and coordinate care plans for each of the assigned patients, and ultimately discharge them from care management. Many patients will have multiple co-morbidities and/or psychosocial needs. The Care Manager will develop an effective supportive relationship with the patient/family to facilitate achievement of the health goals. They will interact and collaborate with interdisciplinary care teams, which include physicians, discharge planners, inpatient case managers, referral coordinators, pharmacists, laboratory technologists, social workers, dietitians and other educators and nurses. The Care Manager RN also acts as an advocate for patients and their families, providing links to relevant services to help them gain knowledge of their disease processes and to identify community resources for continued growth toward the maximum level of independence.
California licensed Registered Nurse
Minimum one year recent (in past three years) clinical nursing experience, must include work with patients 65+ years and experience caring for patients with behavioral health diagnoses.
Incumbents must have own vehicle and valid driver's license with proof of insurance in conformity with state law minimums as these positions may require traveling.
Knowledge and Experience:
Experience in a Medicare and Medi-Cal environment (Home health, Skilled Nursing, Physician Office, Clinic, Hospital)
Knowledge of community resources preferred.
Experience with electronic medical records documentation.
Equal Opportunity Employer
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