Chronic Care Case Manager
Desert Sage Health Centers is currently recruiting an, experienced, energetic full time RN Chronic Care Case Manager to be part of our team. The Case Manager is responsible for planning, facilitating, improving, and coordinating comprehensive services across the continuum of care. Part-time telecommute options will be considered for the right candidate, after relationships with patients and care teams have been established
Purpose of Position: The RN Case Manager develops DSHC’s case management program, and actively works with patients and staff to improve patient outcomes, close care gaps, and ensure comprehensive, life-saving care is received by DSHC’s patients. The Case Manager coaches the staff on the RN-patient-physician collaborative process of assessment, planning, implementation, coordination, monitoring, and evaluation to address patients holistically. This plan includes ongoing screening of the member for changes in health status and coaching for improved self-management. Overall, the RN Case Manager serves as a clinical champion in the health center for improving patient care and safety, improving quality measures, enhancing integration of care team operations, and facilitating clinical-quality improvement efforts.
- Develop and document systems for risk stratification, registry creation and maintenance, closed-loop care (test/lab tracking, referral tracking, etc.), case management documentation, and standard workflows.
- Train providers and other DSHC staff on risk stratification and care-management scope and workflows.
- Assist in implementation, roll-out, ongoing maintenance, and ongoing training of clinical staff DSHC’s population health management tool; assist in the development of workflows that tie together clinical practice and population health data.
- Develop, monitor, and report metrics throughout the health center to identify patient progress and overall success of Care Management program.
- Maximize team-based care by developing strong working relationships with specialty providers and the DSHC care teams.
- Serves as a leader in the health center for improving care, quality measures, enhancing integration of care team operations, and facilitating quality improvement efforts, as demonstrated by leading at least one documented QI project annually
- Supervise care coordinators, including scheduling, delegation of work, team assignments, performance management, coaching, teaching, professional development/training plans, and development of basic clinical and care-management knowledge to support them in their roles.
- Be available to Care Coordinators via in-person, phone, or electronic communications, including responding to messages as soon as possible. Maintain frequent communication with Care Coordinators.
- Delegate appropriate tasks to care coordinators for patient outreach and self-management support, scheduling follow-up and closure of care gaps, connecting patients with community resources, etc.
- Work with care teams and leadership to develop a prioritization list for building and managing case management panels.
- Provide chronic care management to highest risk population, including oversight of patients on Controlled Substance Agreements.
- Facilitates patient medication management based upon standing orders and protocols; includes conducting reconciliation for poly pharmacy patients to ensure medication safety and patient understanding of medication use
- Facilitates health and disease patient education.
- Supports patient self-management of disease and behavior modification interventions.
- Documents chronic care management activities in the EMR to ensure maximum revenue capture; teaches care coordinators and other staff how to document time spent on CCM activities for Medicare/dual eligible patients.
- Establish a mechanism to reliably identify and track patients discharged from inpatient care; ensure patients discharged from the hospital are seen within 7-14 days of discharge.
- Complete post-discharge calls to patients within 72 hours of discharge according to standard scripting (medication review, upcoming appointments, plan of care as outlined by hospital, etc.)
- Build a strong relationship with the hospital, and serve as the patient care liaison to ensure DSHC is able to receive notification and discharge information from the hospital(s) when patients are discharged and/or need follow-up appointments, leveraging health information exchange whenever possible
- Responsible for working preventive care gap lists (with assistance from care coordinators), to ensure high-risk patients receive appropriate screenings and services
- Coordinate services with other service providers, inside and outside of DSHC.
- Promotes clear communication among the care team by ensuring awareness regarding patient care plans.
- Ensure patients with substance abuse and alcohol abuse disorders are connected with appropriate support services.
- Must hold current RN License in Idaho
- BSN degree required
- Must hold current CPR card (healthcare provider)
- 3-5 years of direct experience providing case management to diverse patient populations
- Demonstrated understanding of best practices in chronic disease case management and population health.
- Demonstrated ability to aggregate, analyze, and act upon clinical data
- Demonstrated experience with running quality improvement projects and process improvements preferred
- Bilingual English/Spanish Preferred
If you are self motivated, compassionate, leadership-oriented, and ready to give back to your community, we are looking for you.
Bilingual Patient Registration
As we grow and promote from within, we are searching for a new team member!
A full time Bilingual Patient Registration team member who is self motivated, energetic, customer service with a smile first, for our front desk patient registration department. The right person must be bilingual in Spanish/English, able to multi task, schedule patient appointments by phone and in person, maintain files, tracking systems and data collection activities.
Making sure patients are treated as an individual and have the ability to show compassion is a must.
Must have high school diploma or equivalent. If you meet all of these qualifications please apply!
Behavioral Health Clinician (LMSW, LCSW, LCPC, LSW, LPC)
Desert Sage Health Centers is searching for a Behavioral Health Clinician to join our team. The LMSW/LCSW/LCPC/LPC is responsible for assessing, and if appropriate, treating and connecting individuals in need of behavioral health services to appropriate programs, and/or to other agencies and sources around the community which could meet the individual needs of the identified client. As a licensed clinician, the Behavior Health Specialist will utilize the Screening, Brief Intervention, and Referral to Treatment (SBIRT) Model for brief treatment. Spanish language is preferred but not required. Full-time (40hrs/week)position. If you are looking to give back to your community, please apply.
Behavioral Health Integration Consultant (LMSW, LCSW, LCPC, LSW, LPC)
Desert Sage Health Centers is in search of a dynamic mental health specialist to join our behavioral health integration team. The right candidate will function as part of the integrated health model providing integrated behavioral health services to patients currently receiving primary care services. The Behavior Health Specialist position is the primary interface for patients to access services such as peer/family counseling and support, screening, assessment, brief treatment, consultative services, education and engagement, linkages, outreach and advocacy. As a licensed clinician, the Behavior Health Specialist will utilize the Screening, Brief Intervention, and Referral to Treatment (SBIRT) Model for brief treatment and provide linkage and make referrals to other community and higher-level care providers for patients. Consulting with primary care providers to develop specific behavioral change plans for patients and behavioral health protocols for target populations. Spanish language is preferred but not required. Full-time (40hrs/week)position. If you are looking to give back to your community, please apply.
Please contact Sharlet Wilson today at (208) 696-7203 or e-mail your resume to email@example.com
Apply online:Applications can be accessed below, once the application is filled out you must do one of the following things:
a) Mail it to Desert Sage Health Centers using standard mail (address is at the top of the application)
b) Scan the application and email it to: firstname.lastname@example.org
d) Applications can be delivered to any DSHC clinic in a sealed envelope addressed to Sharlet Wilson to ensure confidentiality