At DAP Health, we are committed to transforming lives and advancing health equity for all. As a leading nonprofit health care provider, we deliver compassionate, high-quality care to the diverse communities of the Coachella Valley and San Diego County. Our comprehensive services range from primary care to mental health, wellness programs, and beyond, with a focus on those who are most vulnerable. Joining our team means becoming part of a passionate, innovative organization dedicated to making a meaningful impact in the lives of those we serve. If you're looking for a dynamic and purpose-driven environment, we invite you to explore the opportunity to contribute to our mission.
Job Summary
The RN Case Manager serves as an advocate and care coordinator for at-risk patients, including those being discharged from the hospital, managing chronic disease non-compliance, newly diagnosed with chronic disease or cancer, frail, elderly, or frequent emergency room utilizers. The RN Case Manager is responsible for conducting an in-depth assessment of a client's needs and providing appropriate
interventions to improve outcomes, ensure access to care, reduce re-hospitalization, and offer support systems for the management of the condition.
Supervisory Responsibilities: None
Essential Duties/Responsibilities
- Conduct a thorough needs assessment based on the risk factor or diagnosis provided at the time of referral - this may include a medical history, functional abilities, and social components including family support systems, ability to function independently, ability to obtain medication and understand the prescription, language skills and medical insurance status
- Arrange and coordinate various services based on the needs of the patient - these may include public or private programs, not-for-profit organizations, transportation, in home support services, medical insurance, patient and family education, home health, medication use, and others
- Assist with paperwork necessary to obtain services
- Maintain adequate knowledge of resources available and conduct additional research when indicated or necessary to resolve complex cases
- Act as an advocate between agencies and clients to ensure timely interventions and develop a collaborative relationship to maximize the patient's and family's ability to make informed decisions
- Demonstrate the knowledge base necessary regarding resources and health care services to appropriately assist the client and communicate effectively with the medical team
- Demonstrate ability to manage the case through the continuum of care towards providing timely interventions and an appropriate outcome
- Provide adequate care coordination, effectively communicate the interventions and progress with the health care team, and conduct timely follow-up assessments
- Maintain appropriate documentation including but not limited to client information, diagnosis, and medical history, communication with service providers, details of the referrals issued, plans, goals, and outcomes
- Make recommendations for changes in the direction of projects based on informed and acquired knowledge of trends and community changes
- Conduct or participate in community meetings as deemed appropriate for the current assignments or potential opportunities of development
- Integrate support functions effectively with the clinic services and operations
- Assist with opening new opportunities for funding or program growth by staying informed and establishing a network of community resources
- Participate in organizational performance improvement projects related to current activities and annual MA Clinical Skills Competency Training events
- Provide patient and clinic support on a case-by-case basis to surrounding clinics
- Offer patient and clinic support as part of the call center RN Triage coverage and assist with special projects requiring RN expertise as needed
- Develop and monitor departmental and program/project operating budgets, costs and schedules
- Supervise, lead, coach, and use best management practices to improve staff performance
- Support and model the identified vision, values, and behaviors of the organization
- Work with staff to develop systems to ensure consistent, high-quality project management
- Other duties as assigned
Safety
- Ensure compliance with policies and procedures related to safe work practices
- Use appropriate equipment and/or tools to ensure workplace safety
- Immediately report unsafe working conditions
Privacy/Compliance
- Maintain privacy and security of all patients, employee, and volunteer information and access to such information
- Comply with all regulations regarding corporate integrity and security obligations
- Report unethical, fraudulent, or unlawful behavior or activity
- Uphold strict ethical standards
Required Skills/Abilities
- Demonstrate excellent oral and written communication skills
- Proficient in thoroughly documenting conversations and actions related to case management
- Exhibit effective interpersonal skills
- Ability to work effectively in collaboration with diverse groups of people
- Proficient in performing mathematical calculations, organizing, and prioritizing workload
- Ability to work effectively and efficiently under stress
- Capable of handling difficult situations with professionalism
- Shows integrity, positive attitude, mission driven attitude, and is self-directed with a demonstrated passion for DAP Health's mission and commitment to working collaboratively with the executive team
- Basic business intuition and common sense
- Strong work ethic
- Skilled in supervising, multitasking, and following instructions
- Proficient in reading, writing, speaking, and understanding English
- Bilingual in Spanish and English is preferred
Education and Experience
- RN Degree
- At least 2 years' work experience in Case Management or related field
- Strong technical knowledge of management principles and practices
Working Conditions/Physical Requirements
- Capable of lifting and moving up to 40 pounds, moving between locations, and standing for extended periods
- Hybrid schedule: 3 days in clinic and 2 working remotely