Job Description
About Heritage Health Network:
Heritage Health Network (HHN) is a leading healthcare organization dedicated to improving the health and wellness of vulnerable populations in Riverside and San Bernardino counties. We are committed to providing Enhanced Care Management (ECM) to individuals at risk of hospitalization supporting birth equity and assisting those at risk of or living with limb loss. By integrating clinical care with essential social support HHN delivers hightouch personcentered services.
Role Overview:
We are seeking a dynamic and experienced Registered Nurse (RN) to lead our Enhanced Care Management (ECM) Care Team as the ECM Care Team Leader. This pivotal role involves overseeing a multidisciplinary team of (3) including a Behavioral Health Care Manager a Lead Care Manager and a Community Health Worker. The team is responsible for delivering comprehensive integrated care primarily driving positive health outcomes.
Requirements
Key Responsibilities:
- Outreach and Engagement: Contact eligible ECM members to inform them about the program and facilitate their enrollment.
- Leadership and Coordination: Lead the ECM Care Team ensuring a holistic integrated approach to patient care.
- Community and InHome Engagement: Meet with members in the community or at their homes to enhance care delivery. Accompany members to medical visits and other appointments as requested.
- Caseload Management: Manage a caseload of 6075 members.
- Comprehensive Care Planning: Conduct comprehensive risk assessments and collaboratively develop PatientCentered Care Plans with members.
- Case Coordination and Support: Serve as the primary contact for members coordinating access to care services and resources. Initiate or participate in case conferences with the member s primary care provider clinical consultant and/or other ECM team members.
- Healthcare Provider Collaboration: Foster partnerships with healthcare providers and communitybased organizations to facilitate the integration of healthcare referrals and access to community resources.
- Transitional Care Coordination: Coordinate with hospital staff on discharge plans and other transitional care as feasible.
- Reporting and Documentation: Contribute to completing monthly reports for health plans and maintaining the internal resources directory.
- Regulatory Compliance and Communication: Ensure compliance with healthcare regulations and HHN policies. Act as the primary point of contact for educating members and their families on healthrelated issues.
Qualifications:
- Licensure: Must hold an active Registered Nurse (RN) license in the state of California.
- Experience: At least 3 years of nursing experience is required with a minimum of 1 year in a leadership or management role.
- Specialized Knowledge: Experience in care coordination and managing complex patient populations preferably within an ECM or similar program.
- Skills: Strong clinical skills necessary to assess plan implement and evaluate patient care effectively.
- Interpersonal Skills: Excellent communication and interpersonal skills essential for working effectively within a multidisciplinary team.
- Regulatory Knowledge: Familiarity with healthcare regulations
- Medicare/MediCal guidelines and care management best practices.
- Commitment: Dedicated to providing patientcentered culturally competent and highquality care.
Benefits
Benefits:
- Health Insurance: Eligible for medical dental and vision insurance from the first of the month following or coinciding with your start date.
- Sick Time and Paid time off.
- Paid Holidays
- Work Flexibility: Opportunity to work from home several days a week.
- Compensation and Incentives: Competitive salary with annual merit increases
- Quarterly Bonus opportunities
- Career Development: Opportunities for career advancement and professional development
Heritage Health Network offers a supportive community and opportunities for professional growth aiming to enhance both patient and employee experiences. Join us in making a lasting impact on community health.
Key Responsibilities: Community Liaison: Serve as a key connection between HHN and the community, enhancing access to healthcare services and resources. Outreach and Engagement: Conduct proactive outreach activities to raise health education and awareness within the community. Healthcare Navigation: Assist members in navigating the healthcare system, ensuring they understand their care plans and steps needed for recovery and well-being. Emotional and Social Support: Provide crucial emotional and social support to clients and their families, especially in hospital or home settings post-amputation. Gap Identification and Solutions: Collaborate with the ECM team to identify gaps in care and develop solutions to address these gaps. Resource Facilitation: Facilitate connections to community resources, including social, educational, and financial assistance programs. Caseload Management: Manage a caseload of 60-75 members, meeting them in the community or at their place of preference. Documentation: Accurately document the dates, time, and nature of services provided to members, integrating this information into the member s medical record. Plan of Care Participation: Participate in the development of care plans in collaboration with the member s care team and licensed providers. Qualifications: Lived Experience: Must have lived experience that aligns with and provides a connection to the members served. This can include experiences related to incarceration, military service, pregnancy and birth, disability, foster system placement, homelessness, mental health conditions, substance use, or being a survivor of domestic violence or exploitation. Cultural Competence: Shared race, ethnicity, sexual orientation, gender identity, language, or cultural background with the community served is highly valued. Passion for Service: Demonstrated passion for community service and healthcare, particularly focusing on vulnerable populations. Communication Skills: Exceptional communication and interpersonal skills, capable of engaging effectively with diverse groups. Organizational Skills: Strong organizational abilities, with the capacity to work independently and as part of a multidisciplinary team. Community Knowledge: In-depth knowledge of local community health needs, resources, and cultural nuances. Experience: Previous experience in community health work, social work, or a related field is preferred but not required. Bilingual Skills: Bilingual abilities are highly valued to better serve our diverse community. Mobility: Must be willing and able to travel within Riverside and San Bernardino counties for home visits and community engagement activities.
Job Tags
Holiday work, Local area,