SUMMARY

Montage Medical Group’s Collaborative Care Services (CCS) department supports patients and care teams in navigating the complex healthcare system with compassion, kindness, and reliability. We are trusted in our knowledge and follow through. We meet our patients where they are and advocate for their needs. Our team consists of Registered Nurse Care Managers, Licensed Vocational Nurse (LVN) Clinical Care Coordinators, Social Workers, Pharmacy Technicians and Care Coordinators (non-clinical).

The Clinical Care Coordinator – LVN is responsible for engaging recently hospitalized patients to ensure appropriate follow up medical care and services are provided. The CCC collaborates with the Care Coordinator (non-clinical), physicians and APPs, clinic medical assistants and care managers to ensure patients’ needs are addressed timely. The Clinical Care Coordinator (CCC) also evaluates the patient for referral to care management, coaching or other resources to assist in supporting the patients’ self-management plans.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

• Responsible for transitional care management services.
• Collaborates with the care team to prevent unnecessary hospital re-admissions.
• CCC regularly exercises discretion and independent judgement in carrying out job duties and assessing patient needs.
• Manages designated aspects of the patient’s care.
• Responsible for being available to provide telephone advice per protocol, handling urgent calls and emergent calls, appropriately referring to or involving physicians/care managers when appropriate.
• Participates in facilitating patient transitions in the care continuum. Serves as the bridge between consulting physicians, hospitals, ER and other frequently used healthcare resources and the patient and/or family.
• Collaborates with the care team in assessing the patient’s progress toward individual health care goals.
• Assesses barriers when the patient has not met treatments goals or is not following the treatment plan of care.
• Participates in measuring clinical outcomes, analysis activities, and quality improvement.
• Participates in any “integrated population management” initiatives to improve the health status of a particular patient population (e.g., diabetics, asthmatics, smokers, COPD, CHF, etc.).

• Other duties as assigned.

EDUCATION: LVN licensed in California. High School diploma or equivalent. American Heart Association BLS.

EXPERIENCE: Experience as an LVN in Care Management or in a Medicare and Medi-Cal environment (Home health, Skilled Nursing, Physician Office, Clinic, Hospital). Experience with electronic medical record documentation.

REQUIREMENTS: California licensed vocational nurse.

MONTAGE VALUES

Employees of Montage Medical Group are expected to uphold the Montage Values and Service Standards. Montage Medical Group employees find joy in caring for those we service, are dedicated to coordinating care across all settings, take ownership, collaborate to deliver the highest quality care and are entrusted to serve our community with respect.

PREFERRED: Bilingual English/Spanish. Knowledge of Monterey County community resources.

KNOWLEDGE: The jobholder must demonstrate current competencies applicable to the job position.

SKILLS AND ABILITIES:

• Skill in appropriate assessment and assistance techniques.
• Skill in appropriate use of universal precautions, safe workplace and confidentiality methods.

• Stays current on care management theories/clinical standards of care and resources available to patients.

• Ability to appropriately interact with patients, families, staff and others.

• Ability to react calmly and effectively in emergency situations.
• Ability to self-direct in keeping with departmental and organizational priorities, policies, and procedures.

• Skill in health information management by appropriately charting patient data.
• Ability to work effectively as a team member with physicians and other staff.
• Ability to flexibly respond to changing demands.

• Ability to plan, organize, prioritize and direct the work of others.
• Strong communication skills, verbal and written.

PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit, use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee is occasionally required to stand; walk; climb or balance; and stoop, kneel, crouch, or crawl. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, color vision, and ability to adjust focus.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

A medical group can be a stressful and high-pressure environment. Individuals must enjoy working in such environments and be willing to adapt the pace of their work and output to the patient volumes and tasks of a medical facility.