REGISTERED NURSE CASE MANAGER

Job PurposeChinatown Service Center (CSC) is a multi-service, community health center, which provides compassionate, multi-lingual and culturally sensitive care to the communities of Chinatown, San Gabriel Valley and beyond.

Our mission is to provide outstanding services and advocacy that promote better quality of life and equal opportunity for immigrants and other communities.

CSC's RN Case Manager performs Annual Wellness Visits for Medicare patients, provides care coordination for patients enrolled in Chronic Care Management, provides Transitional Care Management, and provides case management for the rest of the patients in the medical department.

The Case Manager works with a multidisciplinary team to create a Health Action Plan (HAP) for individual patients. The Case Manager works with the patient, their support system, and the multidisciplinary team to follow and adjust the HAP as needed based on the patient's progress.

Duties and Responsibilities* Perform Annual Wellness Visits for Medicare patients* Provide care coordination for patients enrolled in Chronic Care Management program.

• Provide Transitional Care Management for patients who have recently been discharged from a higher level of care.* Works with the patient, their support system and the healthcare team to create a Health Action Plan (HAP) for their patients.
• Ensures that goals of individual patients HAP are being met.* Acts as liaison between patient, healthcare team, outside consultants, and any other outside resources to help patient follow HAP.
• Offers services where the case management member lives, seeks care, or finds the most easily accessible setting within applicable guidelines.
• Connects case management members to other social services and supports the patient may need.* Advocates on behalf of members with other healthcare professionals.
• Uses motivational interviewing to engage patients in care.* Works with hospital staff on discharge plans.* Engages and outreaches to eligible case management members.
• Monitors treatment adherence and informs teams of any changes or lack of adherence.* Provides health promotion and self-management training.
• Arranges transportation as needed.* Perform other duties as assigned.Qualifications* Graduate of an accredited school of nursing* Licensed as a Registered Nurse in the state of California* BLS certification required* Strong interpersonal skills and critical thinking abilities* Basic computer and Internet skills : MS Word, Excel, and Internet* Familiarity with electronic medical record systems and standards of documentation* Effective oral and written communication skills* Able to work independently and take initiative* Establish and maintain effective working relationships with those contacted in the performance of required duties* Ability to interact with diverse populations and develop good relations with individuals and families* Able to explain designated and specific regulations and procedures to clients* Bilingual in English and Chinese / Spanish preferablyPhysical Demands* Able to obtain vital signs.
• Must be able to remain in a stationary position 50% of the time.* Ability to occasionally move about inside the office to access file cabinets, office machinery, etc.
• Able to operate a computer and other office productivity machinery, such as a calculator, copy machine, and computer printer.
• Able to constantly position yourself to maintain files in file cabinets such as reaching with hands and arms, kneeling, crouching, etc.
• The ability to communicate, detect, converse with, discern, convey, express oneself, and exchange information is crucial for this role.

Direct ReportsChief Medical Officer