RN Case Manager- Home Health North County up to $5K Sign On Bonus

Archer Health Case Manager assists in the planning, coordination, monitoring, and evaluation of patient care services with an emphasis on quality of care, continuity of services, and cost-effectiveness

He/She provides chronic and/or palliative care management to patients with multiple comorbidities, including but not limited to, diabetes, cardiovascular disease, and COPD.

This role involves gathering and evaluating clinical information and accurately documenting it in the EMR. Collaboration with direct care clinicians is paramount in developing and managing personalized care plans for all patients.

Responsibilities:

1. Provide (or delegate) a post-admit phone call to see how the general patient population is doing
2. Offer post-admit calls (some as little as once a month, others maybe weekly) to patients with 4+ co-morbidities and/or end-stage chronic care (palliative care needs with ACP, care coordination/advocacy, and resource assistance
3. Make calls to providers for additional services that may be needed such as RN, HHA, or MSW)
4. Written and/or verbal communication, thru email, K-mail, or Well Sky comm notes, will be provided to Archer Health team members providing direct care to patients
5. All communication related to specific patients will be documented in their EMR.
6. Post-discharge calls will be implemented to watch for signs of exacerbations or potential hospitalizations and the need to resume home healthcare services.
7. Provide clinical assistance to Intake and Scheduling departments. Responsibilities include:
   1. Follow the intake and admission processes as confirmed through OP No. 2-004 and 2-005.
   2. Review written documentation of the patient's demographics, Medical H & P, and SOC order (via email and/or hardcopy) for admission appropriateness and including the need for additional Archer Health services.
   3. Screen patient and inform the patient that a referral was received and give the name of ordering physician or hospital. Always introduce self and state where they are calling from and verify the patient's address.
   4. Carry out other care coordination with administration and clinical providers as neede

Goals

• Provide continuous, quality care to patients to enrich their overall health and well-being.
• Decrease hospitalizations, ER visits, and other inappropriate resource utilization.
• Build a trusting relationship with our more vulnerable patients and their significant others.
• Keep patients happy and healthy at home!