CCHP Public Portal
The Care Coordination Nurse assists members by identifying and managing each
members’ individual, medical and psychosocial care needs and by offering culturally
sensitive and tailored health education. The nurse assures that members have access
to quality, cost-effective health care by assisting in the assessment, coordination,
teaching, and monitoring activities aimed at self-management. The nurse collaborates
and facilitates care with medical service providers physicians, home health providers,
medical equipment vendors, and community resources.
Essential Duties and Responsibilities
Identifies potential candidates effectively by utilizing various CCHP data sources, such as daily inpatient census, internal data, self-referrals, provider referrals, and utilization management staff. Conducts member outreach in response to referrals to assist with member health needs or concerns by phone, mail or any other forms of communication to promote program engagement. Assesses and manages complex medical, psychosocial, cognitive and functional conditions. Identifies early risk factors and conducts ongoing phone assessments when necessary. Assists the member in completing the Health Risk Assessment (HRA) surveys and coordinates with the primary care physician to meet the individual’s care needs. Reviews members’ HRA survey responses for Commercial and the Senior Select (Special Needs Plan) population, checks them against the medical record for accuracy, and then discusses the responses with the member during the outreach call. After the review, the nurse documents findings, identifies care gaps or health risks, and makes appropriate referrals or care coordination as needed. Develops a comprehensive care plan with appropriate interventions consistent with CCHP policy guidelines and Medicare/Medicaid requirements within the care management system. Gathers input from the member and/or responsible parties in the development of the care plan. Modifies the plan of care through monitoring and re-evaluation to accommodate changes in treatment or progress for assigned members. Documents all activities in CCHP’s care management system to allow for continuity of care. Performs post discharge follow up, case management, and disease management duties through promoting healthy lifestyles, closing gaps in care, reducing unnecessary ER utilization and hospital readmissions. Provides members with appropriate education to enhance their knowledge related to health or lifestyle management. Identifies medically complex members and consults with others on the interdisciplinary team. Works collaboratively with others on the interdisciplinary team in assessing, planning, and providing services to members. Assists in coordinating communication between doctor’s office, clinics, hospitals, member/families, home health agencies, vendors, and CCHP staff. Utilizes evidence-based guidelines such as InterQual Guidelines and to identify member’s needs and provide care coordination support. Collaborates with the Utilization Management (UM) department and assists with UM activities to help members navigate the approval process, optimize quality of care, and promote cost-effective practices. Maintains a caseload panel through prompt identification and response to cases appropriate for level of care changes including discharge or transfer activities. Monitors & reports outcomes of the member weekly/ monthly as requested. Participates in team meetings. Accepts and performs other duties as assigned. Qualifications
Bachelor’s degree or equivalent preferred Excellent verbal and written communication skills Bilingual in English and Chinese (Cantonese) Ability to set and change priorities quickly or as the situation warrants Able to work independently and as team player Proficiency in Word and Excel Ability to maintain high volume workload without compromising quality Minimum two years acute inpatient care experienced preferred At least one-year recent utilization management or case management experience preferred Physical Requirements
Able to lift up to 30 pounds Use proper body mechanics when handling equipment Standing, walking and moving 50% of the day. Compliance Requirements
Complies with CCHP Compliance Handbook including Code of Ethics and all statutes, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs. Base Pay Scale
Starting at $40.63 – $60.89 per hour. The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.
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Identifies potential candidates effectively by utilizing various CCHP data sources, such as daily inpatient census, internal data, self-referrals, provider referrals, and utilization management staff. Conducts member outreach in response to referrals to assist with member health needs or concerns by phone, mail or any other forms of communication to promote program engagement. Assesses and manages complex medical, psychosocial, cognitive and functional conditions. Identifies early risk factors and conducts ongoing phone assessments when necessary. Assists the member in completing the Health Risk Assessment (HRA) surveys and coordinates with the primary care physician to meet the individual’s care needs. Reviews members’ HRA survey responses for Commercial and the Senior Select (Special Needs Plan) population, checks them against the medical record for accuracy, and then discusses the responses with the member during the outreach call. After the review, the nurse documents findings, identifies care gaps or health risks, and makes appropriate referrals or care coordination as needed. Develops a comprehensive care plan with appropriate interventions consistent with CCHP policy guidelines and Medicare/Medicaid requirements within the care management system. Gathers input from the member and/or responsible parties in the development of the care plan. Modifies the plan of care through monitoring and re-evaluation to accommodate changes in treatment or progress for assigned members. Documents all activities in CCHP’s care management system to allow for continuity of care. Performs post discharge follow up, case management, and disease management duties through promoting healthy lifestyles, closing gaps in care, reducing unnecessary ER utilization and hospital readmissions. Provides members with appropriate education to enhance their knowledge related to health or lifestyle management. Identifies medically complex members and consults with others on the interdisciplinary team. Works collaboratively with others on the interdisciplinary team in assessing, planning, and providing services to members. Assists in coordinating communication between doctor’s office, clinics, hospitals, member/families, home health agencies, vendors, and CCHP staff. Utilizes evidence-based guidelines such as InterQual Guidelines and to identify member’s needs and provide care coordination support. Collaborates with the Utilization Management (UM) department and assists with UM activities to help members navigate the approval process, optimize quality of care, and promote cost-effective practices. Maintains a caseload panel through prompt identification and response to cases appropriate for level of care changes including discharge or transfer activities. Monitors & reports outcomes of the member weekly/ monthly as requested. Participates in team meetings. Accepts and performs other duties as assigned. Qualifications
Bachelor’s degree or equivalent preferred Excellent verbal and written communication skills Bilingual in English and Chinese (Cantonese) Ability to set and change priorities quickly or as the situation warrants Able to work independently and as team player Proficiency in Word and Excel Ability to maintain high volume workload without compromising quality Minimum two years acute inpatient care experienced preferred At least one-year recent utilization management or case management experience preferred Physical Requirements
Able to lift up to 30 pounds Use proper body mechanics when handling equipment Standing, walking and moving 50% of the day. Compliance Requirements
Complies with CCHP Compliance Handbook including Code of Ethics and all statutes, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs. Base Pay Scale
Starting at $40.63 – $60.89 per hour. The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.
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