Akira Health Inc. is an accountable care organization (ACO) developed under the Affordable Care Act that provides high-quality care to Medicare patients. The main goals of an ACO structure are to enhance the quality and effectiveness of care delivered while improving efficiency.
The nurse case manager provides ongoing support and expertise through implementation of evidence-based interventions following a comprehensive assessment and evaluation of individual patient needs. The overall goal of this full-time position is to promote continuity of care and cost effectiveness through care coordination, case management, and discharge planning of high-risk patients. This position is accountable to the ACO Case Management Director.
Registered Nurse licensed in the state of California with at least 1 year of experience in case management preferred but not required. Proficiency in Spanish or Vietnamese is a plus.
SUMMARY OF MAJOR AND ESSENTIAL FUNCTIONS
The nurse case manager works with the patient’s primary care provider and on-site medical director to provide care coordination across the entire continuum of care, including inpatient, outpatient, SNF, and home. He or she provides risk evaluation and care coordination (telephonic and home visits) to non-acute chronically-ill patients who are identified as high-risk via proprietary algorithms. Should a patient require hospitalization, the nurse case manager collaborates with hospital case managers during hospital stays and discharge planning then follows up shortly after discharge to ensure execution of discharge instructions.
DUTIES AND RESPONSIBILITIES
- Provides telephonic case management and home visits as necessary
- Evaluates and continuously re-evaluates patient health status, basic mental status, social support network, current assistance, home safety, and overall risk
- Assesses patient baseline and generates a treatment plan, which may be modified as necessary throughout the course of the case
- Communicates treatment plan and case status updates with the patient’s primary care provider and on-site medical director
- Coordinates patient care across the continuum of care (hospital, clinic, SNF, and home)
- Carries out evidence-based interventions
- Mobilizes clinical resources to deliver the right patient care at the right time
- Refers cases to physical therapy, social services, etc. as needed. Coordinates with these other services to monitor case status.
- Promotes effective and efficient utilization of clinical resources
- Uses internet-based case management portal for scheduling, case review, and documentation of all encounters (training provided)
- Other activities as assigned
KNOWLEDGE, SKILLS AND ABILITIES REQUIRED
- Ability to communicate technical information to non-technical personnel
- Ability to evaluate patient and develop, implement, and modify care plans
- Ability to travel within Santa Clara County as needed
- Organizational and coordination skills
- Strong interpersonal and communication skills
- Ability to identify process issues and work through solutions (case review)
- Ability to adapt quickly to changes
- Proficiency with Microsoft Office, specifically Excel
TYPICAL WORKING CONDITIONS
This position is largely sedentary. May require some travel within Santa Clara County during work hours.
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