Provide professional and friendly proactive care and triage for clinical issues.
Embed a family centered care philosophy in care delivery.
Demonstrate cultural competence and sensitivity as ability to work with culturally diverse populations and seek out additional resources when needed.
Transition of care for ED/IP/UC care coordination with clinical providers following discharge.
Perform a comprehensive assessment of a patient’s clinical, psychosocial, discharge planning and financial needs. Establishes clinical milestones and goals related to these issues.
Establish rapport and a relationship with the patient and family in order to understand their needs and expectations and to assist them in setting realistic and mutual goals. Integrate an awareness of cultural factors in the patient/family interview process and elicit clinically relevant cultural information.
Establish, in conjunction with the physician, the patient and interdisciplinary team, a comprehensive plan of care to appropriately address clinical milestones.
Communicate plan of care, including changes and issues related to plan of care to patient/family, physicians and other members of the healthcare team.
Gather sufficient information from all relevant sources to determine the effectiveness of the plan of care to assure it is done in an accurate, safe, timely and cost-effective manner.
Document all care management assessments and interventions.
Refer to Social Worker or Behavioral Health for complex psychosocial and discharge planning issues (per criteria) and ensures appropriate follow-up. Consults with other members of the interdisciplinary team (dietary, pharmacy, etc.) to provide safe discharge as appropriate.
Perform other duties as assigned
Requirements
Licensed RN in at least one state with eligibility to register for other state licensures.
Bachelor’s in nursing from an accredited university required.
Pediatrics experience required in outpatient (primary care and/or subspecialty), home health, complex care, pediatric ICU, emergency medicine, etc.
Minimum 1 year care coordination or case management experience preferred.
Bilingual Spanish required
Familiarity with Medicaid regulations and services a plus
Value Based Care (VBC) experience a plus
Virtual care experience a plus
Benefits
Competitive medical, dental, and vision insurance
Healthcare and Dependent Care FSA; Company-funded HSA
401(k) with 4% match, vested 100% from day one
Employer-paid short and long-term disability
Life insurance at 1x annual salary
20 days PTO + 10 Company Holidays & 2 Floating Holidays