Job Overview

Join a company ranked among the TOP 25 Companies to Work for in Los Angeles!
Join AltaMed’s team of multicultural health care professionals in serving more than 150,000 families a year. Our integrated system emphasizes prevention and healthy living to reduce health care disparities in multi-ethnic communities and avoid unnecessary trips to the emergency room or other more costly forms of care.

AltaMed is the largest independent Federally Qualified Community Health Center in the U.S., with more than 930,000 annual patient visits. Our culturally competent physicians and health care professionals provide integrated primary care services, senior care programs, and health and human services at 43 accredited sites in Los Angeles and Orange Counties. Established in 1970, AltaMed is proud to be a national model for the delivery of quality, patient centered care to underserved communities. We currently have an excellent opportunity for the following:

Patient-Centered Medical Home Clinical Care Coordinator Nurse, (RN)
Boyle Heights Clinic
Full Time – Regular, Position Req. #12

Responsibilities

  • Provide daily care coordination, case management, coaching, consultation, and intervention to patients with one or more chronic diseases.
  • Identify prospective patients via provider/clinic referral, utilization management referral, disease registry reporting mechanisms, and patient self referral.
  • Coordinate health care services for patients through assessment of their chronic conditions and/or other health care needs.
  • Complete Health Risk Assessment to develop Individualized Care Plan.
  • Document ICP and care coordination in case management module database (AltaMed Net, NextGen, EZ Cap, etc.).
  • As part of an interdisciplinary team, coordinate services such as social work, mental health counseling, psycho-social support, in-home support, legal, skilled nursing, home health, etc.
  • Guide service delivery throughout the care continuum to ensure efficient, quality care.
  • Facilitate and coordinate services to develop patient-centered, individualized, integrated self-management plans.
  • Engage patients and their caregivers in understanding and setting self management plans.
  • Support the PCP to implement integrated plans that achieve desired outcomes and satisfy contractual/regulatory requirements.
  • Collaborate with health care providers across the care continuum to ensure patients are effectively managed and health care needs are met.
  • Provide disease specific educational support and in-services to clinic staff.
  • Refer patients to the corporate case management team based on acuity level and/or complex case management needs.
  • Monitor ongoing services and their cost effectiveness; recommend changes using clinical evidence-based criteria – Milliman, Interqual, CMS, and/or national, recognized American academy of specific specialty.
  • Review and process referral authorizations each day in accordance with TAT standards set by ICE/Health Plan requirements.
  • If a current advanced practice degree is held, CCC may play a disease management role.

Qualifications

  • Current, active and unrestricted RN license or certification in a health or human services discipline that allows the professional to conduct an assessment independently
  • Bachelor’s degree in Social Work, Nursing, or another health or human services field with the appropriate licensure preferred
  • Minimum 3 years’ acute care clinical experience or public health nursing required; minimum 2 years’ managed care experience in case management with focus in inpatient and/or outpatient ambulatory care preferred
  • CPR/First Aid certificate
  • Case Management Certification (CCM) preferred
  • Bilingual: English/Spanish/Mandarin/Cantonese (depending on location) preferred
  • Excellent customer service skills
  • Ability to resolve complex customer service issues and exercise conflict management
  • Ability to read, write and speak in a clear and professional manner; includes active listening skills and understanding of medical terminology
  • Ability to complete basic/intermediate math computations and medical math conversions
  • Proficiency in beginning/intermediate computer skills and typing
  • Attention to detail, as well as excellent follow through, multi-tasking and prioritization skills
  • Knowledge of the Case Management Process, Chronic Care Model and Patient-Centered Medical Home Model (PCMH)
  • Ability to apply critical thinking skills and sound judgment throughout the patient care continuum and to make necessary referrals on behalf of Patient/Provider/Caregiver (P/P/C)
  • Knowledge of regulatory requirements, health plan contracts, governmental benefits, and community resources

AltaMed offers extensive opportunities for professional development, as well as competitive salaries and excellent benefits. Our team members enjoy medical, dental and vision plans, retirement plan with matching employer contributions, tuition reimbursement, continuing education programs, and much more. We invite you to join us in making a difference in our communities and in the lives of others.

For immediate consideration, please apply online at AltaMed.org.

AltaMed is fully committed to Equal Employment Opportunity and to attracting, retaining, developing, and promoting the most qualified employees without regard to their race, gender, color, religion, age, or any other characteristic prohibited by state or local law. We are dedicated to providing a work environment free from discrimination and harassment, and where employees are treated with respect and dignity.

View a full list of open positions and apply online at AltaMed.org.

AltaMed is accredited by The Joint Commission. EOE M/F/D/V