West County Health Centers provides comprehensive, quality and accessible health care services to the communities of Western Sonoma County. We are a cohesive team of health care providers, support staff and volunteers dedicated to wellness, compassion, affordability and excellence of care. We believe in non-judgmental and equal care for all members of our diverse community. Come and be a part of an amazing team!

Want to see more about our mission, who we are, and why you should join our team? Check out our video: https://vimeo.com/720057373

Sign-on Bonus of $5,000! New Grads are welcome to apply!

JOB SUMMARY: The Nurse Care Manager is a member of the nursing team, whose primary focus is assisting providers and patients in the area of nursing case management. Position is for full-time hours, hours negotiable.

RESPONSABILITIES:

• Work as part of the clinic nursing team to provide a full range of nursing services including floor nursing, patient triage, phone advice, case management, Care Team coordination, and patient education.
• Work closely with the Primary Care Provider and clinical Care Team in providing Nurse Case Management which may include: a) Coordination of care within primary Care Team; b) Proactive management of patients with chronic illness with poor clinical outcomes or with complex healthcare needs; c) Assist patients in care management and system navigation with recent critical diagnosis; d) Manage critical abnormal lab/DI results; e) Provide management of Care Team’s “Care Transitions” program for patients discharged from an inpatient setting; f) Active participation in Care Team’s “High Risk Case Management” program; g) Provide home visits as indicated.
• Assess, identify problems, plan goals, monitor and evaluate client plans and develop strategies that meet the clients immediate and long term needs.
• Work closely with Primary Care Provider to manage patient “Care Items” which could include: medication refills per protocol, lab triage, document management, management of durable medical equipment, prior authorizations of needed medications or other services, and other items as needed.
• Coordinate population management of Care Team patient panel.
• Provide proactive utilization management for patients with high risk needs, inappropriate utilization of Emergency room services and with complex medication needs.
• Assist patients in obtaining appropriate medications and other medical supplies and equipment including coordination of Pharmaceutical Patient Assistance programs.
• Participate in patient and staff education.
• Provide Nurse visits for designated conditions per clinical protocol.
• Coordinate Care Team support for patients with new health management goal.
• Coordinate tracking of patients for follow-up and continuity of care which may include: a) Developing and using practice guidelines and protocols; b) Use of flow sheets, problem lists, and medical data bases; c) Development and use of critical pathways; d) Tracking outcomes and reporting to primary care provider; e) Tracking and expediting referrals.
• Assist with discharge planning / home care referrals.
• Provide, in collaboration with the Behavioral Health Team, assessment, diagnostic, and intervention services for clients who are overwhelmed by an acute episode, or for those others who have limited self-care abilities.
• Oversee Care Team Medical Assistant administration of immunizations and medications, both injection and oral within the office visit.
• Participate in Care Team meetings to include daily huddles, monthly care team meetings, complex care case conferences and other related meetings.
• Participate in quality improvement, quality assurance, and innovation activities to ensure optimal level of care delivery at West County Health Centers.
• Work collaboratively with Care Team to optimize communication, coordinate needed services and meet the needs of the patient.
• Participate in activities related to addressing the social determinates of a patient’s health.
• Work collaboratively with the Care Team to complete needed patient care items.
• Work with Care Team to actively manage the patient schedule to optimize efficiency, patient experience, and meet the needs of the patient.
• Assist in the coordination of warm hand-offs or “Transfer of Trust” between Care Team, Behavioral Health Staff, or other support services during the office visit.
• Actively seek out opportunities to assist other team members in collaboratively meeting the needs of the patient and Care Team.
• Assist in the adoption and implementation of new technologies and activities that improve patient care and clinic efficiencies.

MINIMUM REQUIREMENTS:

• Current California Registered Nurse License (RN)
• Current BLS CPR certification
• Must be able to perform the physical demands of the job.
• Basic office and equipment safety knowledge and practice
• Basic computer skills
• Excellent communication skills

EXPECTATIONS:

• Attendance and punctuality is necessary.
• Ability to work well with a multidisciplinary team.
• Ability to problem solve and be self motivated with acute attention to detail.
• Must have a commitment to excellence and high standards.
• Must comply with all federal, state and local laws and regulations, and WCHC policies.
• Must have excellent written and oral skills, strong organizational and analytical skills.
• Must comply with all federal, state and local laws and regulations, and WCHC policies.
• Must have ability to manage priorities and workflow.
• Required to have versatility, flexibility and a willingness to work within constantly changing priorities with enthusiasm and positive attitude.
• Strong interpersonal skills and have the ability to understand and follow written/verbal instructions.
• Required to have the ability to deal effectively with a diversity of individuals at all organizational levels
• Demonstrate a positive customer service, patient centered approach at all times.

PHYSICAL REQUIREMENTS:

• Ability to bend and move arms with sufficient range of motion to complete patient related requirements, hearing required for patient assessments, may need to assist patients onto exam table, able to lift 30 lbs., bend, kneel and twist as needed.
• Prolonged standing and occasional sitting required.
• Must be able to perform the essential duties with or without accommodations. Basic office and equipment safety knowledge and practice.

West County Health Centers celebrates diversity and are committed to creating an inclusive environment for all employees. We comply with applicable federal and state civil rights laws and does not discriminate based on race, ethnicity, color, national origin, citizenship, alienage, religion, creed, sex, sexual orientation, gender identity, gender expression, age, disability, or any other status protected by applicable laws.

Job Types: Part-time, Full-time

Pay: From $45.00 per hour

Benefits:

• 403(b)
• 403(b) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Medical specialties:

• Primary Care

Schedule:

• Monday to Friday

Work setting:

• Clinic
• Outpatient

COVID-19 considerations:
COVID vaccine and booster required for employment.

Experience:

• Nursing: 1 year (Preferred)
• Case management: 1 year (Preferred)

License/Certification:

• Registered Nursing license (Required)

Work Location: In person