Primarily work with and support a caseload of individuals with complex medical needs
Work with individual to identify health/wellness goals and incorporate goals into a Shared Care Plan
Educate individuals on medical and behavioral health conditions (including medication) to improve health literacy
Provide medication reconciliation in collaboration with the individuals’s pharmacy
Provide care management services such as coordinating prescriptions and completing prior authorizations
Track and assure that all required assessments and screenings are performed
Collaborate with multidisciplinary care team to identify and address barriers to care
Identify clinical needs and triage escalations, providing brief interventions as necessary, with support from nurse practitioner clinicians
Collaborate on care issues with Enhanced Care Management team by participating in systematic case reviews
Consult with Enhanced Care Management team about clinical concerns or questions, provide educational training on chronic disease states, prevention, treatment, meds, and healthy living
Build trust and develop relationships with individuals experiencing homelessness, living with Severe Mental Illness/Substance Use Disorder, and living with multiple chronic conditions
Use relationship-based strategies to engage individuals in care, understanding that many may have lived personal experiences causing them to be initially hesitant or distrusting of the health care system
Seeks to listen openly to individuals and meets them where they are – understanding that adopting an “it’s not my fault but it is my problem” attitude in all communication styles and approaches
Requirements
Must hold active Registered Nurse license issued by the state of California
Located in California (Preferred)
Previous experience in care coordination or case management
2-3+ years of experience working for a health plan or at-risk provider
Bilingual – English/Spanish
Strong technical skills and comfort with new technology innovation, past experience with CRM databases, basic Google suite, email, and video conferencing
Must have quiet and HIPAA-compliant at-home work environment with reliable Internet connection and cell phone
Strong understanding of cultural fluency
Demonstrated professional or personal lived experience working closely with individuals experiencing complex chronic needs, homelessness, or Severe Mental Illness/Substance Use Disorder
Empathetic with a drive to reduce barriers to healthcare and social services for underserved communities.
Benefits
Comprehensive health, vision & dental insurance
401k
Opportunity for rapid career progression with plenty of room for personal growth!
Monthly $100 work from home expense stipend
Flexible vacation policy with unlimited time off
Work entirely from the comfort of your own home - no office
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