Outreach Care Plan Manager

Job Summary
Salary-Grade 12/13-RN; $88,621-$137,000, Grade 7/8-LVN; $49,960-$71,932/annual salary exempt; Under the direction of the Outreach Director the Registered Nurse (RN) or qualified Licensed Vocational Nurse (LVN) will work with the ECM program staff to provide team-based, patient-center care management for homeless and at-risk individuals, families, and population groups. This position will identify patients who are eligible for ECM or Community Supports (CS) services. Licensed as Registered Nurse (RN) with Bachelor's Science in Nursing (BSN), Public Health Nursing (PHN) Certificate preferred, two years as Registered Nursing experience, or Two years Licensed Vocational Nurse (LVN). Clean driving record and valid drivers license.

Duties

1. Policies and procedures shall be developed, implemented, updated and revised as is appropriate, but no less than annually and submitted to the Policy Coordinator and Board for review and approval.

2. The Outreach Care Plan Manager will provide information and support in a manner that promotes understanding and inclusivity regardless of native language or education level of patients. This is imperative since they serve as the primary point of contact for patients, Medi-Cal Managed Care Plans, and ECM case managers.

3. Ensuring the provision of CHW services comply with all applicable requirements (Refer to CHW Prevention Services information). Medi-Cal covers community health worker (CHW) services, pursuant to Title 42 of the Code of Federal Regulations, Section 440.130(c), as preventive services and on the written recommendation of a physician or other licensed practitioner of the healing arts within their scope of practice under state law.

4. Develop written Care Plans and make written recommendations within the RN’s or LVN’s scope of practice for CHW/ECM services as an identified licensed provider. Review plan of care at least every six months from effective date of the initial plan of care.

5. Determine if progress is being made toward the written objective and whether services are still medically necessary. If there is a significant change in the recipient’s condition, providers should consider amending the plan for continuing care or discontinuing services if the objectives have been met.

6. Develop and maintain a Perinatal Service Program with PHC. Work with PRHS’s Chief Medical Officer (CMO) and Outreach Director.

7. Functions as perinatal case manager as a RN or qualified LVN within the PRHS Partnership HealthPlan Perinatal Services (PHPS), American Indian Maternal Support Services (AIMSS) and Family Spirit programs.

8. In collaboration with the Outreach Dept. Director will utilize a variety of methods to identify eligible patients who may benefit from CHW/CS proactively through the use of information such as:

a. Medi-Cal enrollment data

b. Screening or assessment data, when available (ex: HRA, IHA, HIF, ACEs, etc.)

c. Clinical information on physical and/or behavioral health

d. Severe Mental Illness (SMI)/Substance Use Disorder (SUD) data, when available

e. Risk stratification information for children in PHC’s Whole Child Model (WCM)

f. Other cross-sector data and information, including housing, social services, foster care, criminal justice history, and other relevant information

g. Identification and referral by internal PHC departments (ex: Care Coordination, Claims, Utilization Management, Quality, Member Services, Population Health Management, etc.)

9. Work closely with PHC’s Care Coordination department upon internal identification or direct referral for a patient who may benefit and/or be eligible for one or more CS services through the completion of the PHC Cal-AIM: Community Support Services Referral Form.

a. Document, coordinate and ensure closed-loop referrals and service delivery with their ECM case manager.

b. Be responsive to follow-up communication from PHC if referral lacks required information to prevent the cancelation of services.

10. Required to advise a patient and have a working knowledge of each CS service definitions and responsible for determining their eligibility using their professional judgment if a service, or combination up to 5, is likely to reduce or prevent the need for acute care or other Medicaid services, including but not limited to inpatient hospitalization, skilled nursing facility stays, or emergency department visits.

11. Maintain detailed records and documentation, track data, and generate reports to support program analysis and quality improvement initiatives. Compile and submit necessary medical/statistical reports and data in a timely fashion.

12. Attend training as required by program needs and as requested by Director of Outreach.

13. Ensure program developments are in accordance with the target populations culture and traditions. Must demonstrate empath and professionalism during interactions with patients.

14. Apply basic time management and patient care coordination skills to effectively provide nursing and health care services.

15. Perform related duties and responsibilities as required.

Requirements

1. (A) Licensed as Registered Nurse (RN) with Bachelor's Science in Nursing (BSN) degree from an accredited college or university with major course work in nursing, preferred. Public Health Nursing (PHN) Certificate, preferred.

2. OR (B) Two years as Registered Nursing experience.

3. OR (C) Two years Licensed Vocational Nurse (LVN).

4. Demonstrates knowledge of applicable state professional practice guidelines for registered professional nurses, the American Nurses’ Association Scope and Standards of Practice for Public Health Nursing any other Federal and State laws and regulations applicable to practice as a public health nursing professional.

5. Demonstrates knowledge of research techniques and principles as well as quality assurance/improvement systems.

6. Demonstrates knowledge of data collection, analysis and interpretation techniques.

7. Ability to develop a Care Plan to support ECM Services in accordance with CalAIMs guidelines and IHS guidelines. Understanding the Scope of Practice for ECM care coordination.

8. Ability to work with groups including facilitation, collaboration, negotiation and conflict resolution.

9. Excellent communication skills, follow instructions, and perform duties independently.

10. Clean driving record and valid driver’s license. Willing to travel.

11. Ability to work with Medical, Dental, Behavioral Health departments for Outreach target population.

12. Ability to establish and maintain effective working relationships with employees, general public, other departments, agencies and state officials and work with person with varying levels of education, understanding and values in a culturally sensitive manner.

13. Ability to apply common sense understanding to carry out instructions in written, oral, or diagram form.

14. Ability to deal with problems involving several concrete variables in standardized situations.

15. Willing cross train within department.

16. Ability to work occasionally on weekends and evenings related to program needs.

17. Possess a current CPR card.

18. Must be willing to submit to and pass a pre-employment drug screening test.

19. Preference will be given to Native Americans in accordance with P.L. 93-638.

This position offers an exciting opportunity for individuals passionate about community service and eager to lead impactful outreach initiatives.

Job Type: Full-time

Pay: $49,960.00 - $137,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Work Location: In person

Salary : $49,960 - $71,932