Nurse Care Manager
Company: Landmark Health
Location: Daly City
Posted on: January 12, 2021
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Job Description:
Job DescriptionDo you want to make a difference in healthcare?
Landmark Health was created to transform how healthcare is
delivered to the most medically vulnerable members in our
community. Our medical group provides home-based medical care to
chronically ill patients, many of whom are frail, elderly and
ill-equipped to navigate our overwhelming healthcare system.
Because many of our patients are frail and elderly, we deliver care
primarily in the comfort of their home. Our Program is also offered
to eligible patients at no incremental financial cost to them . We
are not a fee-for-service practice; we benefit economically only if
we deliver high-quality patient outcomes and satisfaction. As a
result, our clinical teams can spend quality-time caring for a
smaller number of patients, giving all patients the space, respect,
compassion and care they deserve. Our model is finding success
throughout the country; we are now the nation's largest risk-based,
in-home medical group. At Landmark, our interdisciplinary teams
collaboratively manage our complex patient panels. These teams are
led by Physicians, Nurse Practitioners, and Physician Assistants,
with supporting care provided by RN Nurse Care Managers, Social
Workers, Pharmacists, Behavioral Health and other employed team
members. The Nurse Care Manager (NCM), is an integral part of the
Interdisciplinary care team (IDT), and is responsible for the
overall care management process for high acuity engaged Landmark
patients. The NCM has oversight for developing patients' plan of
care, providing education, guidance and support. Professionals in
this role elicit input from the IDT based on initial comprehensive
and ongoing assessments of the patient. The NCM uses nursing
assessment and evaluation skills to help guide treatment and care
decisions of the team and identifies services and vendors for
needed care while navigating patient benefit plans. The NCM works
collaboratively with a multidisciplinary team to provide supportive
care to enrolled patients. The IDT multidisciplinary team consists
of the PCP, specialists, behavioral health clinicians, mid-level
practitioners, pharmacist, nutritionist and social worker and the
patient, family and/or caregiver. The NCM ensures that medical
services are managed in the most effective and appropriate health
care setting according to the patient's medical condition. The plan
of care addresses the clinical condition and psycho/social needs to
maximize his/her level of functioning and establishes and maintains
communications with all parties. --- Acts as an advocate for the
patient in all activities including nursing assessments, care
coordination, care plan development, and communication ---
Completes an initial and ongoing patient assessment, including a
medical record review where available --- Documents current advance
care directive status and ongoing efforts to reconcile
patient/caregiver goals with the current clinical status ---
Initiates and maintains ongoing communications with clinicians and
primary care physician --- Engages with families/responsible
parties to collaborate on plan of care and discussion of the
ongoing management of the patient's condition --- Coordinates care
needs are met across the continuum of care delivery model, as the
point of contact for patient/caregiver and clinicians --- Acts as
liaison between providers, nursing facilities, hospitals and
program staff, including making recommendations about care
alternatives or equipment that will aide in the safety of the
patient while promoting optimal clinical outcomes --- Monitors
patient progress against plan of care goals with an emphasis on
patient care needs during transitions and health changes ---
Monitors patient during admissions and provides nursing/assisted
living facility and provider training on program philosophy and
approach to patient care --- Educates patients and/or
families/responsible parties on disease processes and ways to
manage disease progression as independently as possible ---
Identifies and reports any quality-of-care issues and maintains
HIPAA compliance as it relates to patient care --- Current RN
License is required, BSN is preferred --- 1+ years of utilization
management experience preferred --- 3+ years of clinical practice
in a hospital, clinic, home care, or nursing home setting highly
desired --- Case management experience highly desired --- Disease
management and/or physician office experience desired In order to
work with potentially vulnerable patient populations and to keep
employees healthy while caring for patients, all patient-facing
employees of Landmark must provide evidence of the following
required immunizations/vaccinations as a condition of employment:
TB, MMR, Tdap, and Influenza. Declinations may be accommodated
based on your medical history, an allergy or religious beliefs.
Please immediately contact HR if you wish to apply for an exemption
from our vaccination requirements so that we may determine if you
qualify for an accommodation.
Keywords: Landmark Health, Daly City , Nurse Care Manager, Healthcare , Daly City, California
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