Nurse Care Manager
Company: Landmark Health
Location: Beverly Hills
Posted on: January 11, 2021
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Job Description:
Do 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 desiredIn 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, Beverly Hills , Nurse Care Manager, Executive , Beverly Hills, California
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