Nurse Case Manager (RN) - Monday-Friday Role!

About Sage Health

We believe all seniors regardless of means deserve concierge primary care & wellness, without the concierge fees. They've earned it.

Sage Health builds enriching neighborhood health centers that are easy to access, provide or arrange for all of our patients' healthcare needs, and partner with Medicare Advantage plans that fully cover primary care. Unlike other physician practices, a Sage Health physician has a patient panel of 400 or less, and we collaborate with the best outcomes-oriented specialists and hospitals in each market. Because we are not a fee-for-service provider and manage patients within a global capitation budget provided by Medicare Advantage plans, our only concern and motivation is to keep our seniors healthy.

Sage Health is a destination for the best risk provider talent in the country who are building the new standard-bearing senior model for the United States.

About the role

What you"ll do

PRIMARY RESPONSIBILITIES:

Ensure patient information remains secure and confidential.

Maintains a safe, secure, and healthy work environment by following Sage Health policy and procedures, complying with legal regulations.

Create and manage the plan of care for patients with chronic or serious conditions such as diabetes, heart disease, chronic heart failure, and cancer etc.

Advocate for personalized treatment options that address a patient's unique care needs.

Schedule patients' hospital post discharge appointment, within 72 hours (3 days) post discharge and follow up to ensure they attended.

Communicate about a patient's health condition with the patient and their family.

In collaboration with the patient"s primary care physicians offer education and guidance for navigating complex medical decisions.

Serve as a liaison between patients and their insurance providers to promote quality, cost-effective care with the best patient outcomes.

Verifies daily Sage Health patient hospital census and planned discharges.

In collaboration with the Chief Medical Officer or designee, identifies and provides appropriate resources and information to assist patients and their family members related to their diagnosis.

Holds regular cadence of meetings, and communications with the following: clinical support staff, physician, and operations leadership.

Assist primary care physicians in executing virtual appointments in patients" home.

Ensures the overall quality of healthcare for each patient.

Ensures patient electronic health records are updated with the most recent medical treatments

Assist primary care physicians in executing virtual appointments in patients" home.

Maintains a state of readiness for health plan audits, local, state, and federal inspections.

Responsible for staying up to date and knowledgeable of all nursing regulations in support of the clinical staff.

Perform other duties as assigned

Qualifications

REQUIRED QUALIFICATIONS:

B.S. Degree in Nursing

Valid and active Registered Nurse license in the state of employment.

Certification in Basic Life Support

2-3 years" experience working in an inpatient, outpatient I.e., Home Health, Hospice, or health plan case management.

Strong knowledge of clinical assessment skills and experience with chronic disease management

Experienced working in medically underserved/culturally diverse communities

Excellent interpersonal, written, and verbal communication skills

Must be organized and attentive to detail.

Ability to manage competing priorities.

Ability to work in a fast-paced environment

Resourcefulness in problem solving

Able to take and follow through with assigned tasks and accountability.

Valid driver"s license, car insurance, and access to an automobile

Must be able to travel between multiple healthcare facilities I.e., centers, hospitals, skilled nursing facilities, and patient homes.

Strong knowledge of clinical assessment skills and experience with chronic disease management

Experience working with an electronic health record

Must be skilled in web navigation and use of mobile hotspots.

Experience with Microsoft Office Word, Outlook, and Excel.

Full COVID-19 vaccination (including boosters) an essential requirement of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. Sage Health will adhere to all federal, state, and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance

PREFERRED QUALIFICATIONS:

Certification in Case Management I.e., ACM (Accredited Case Manager) or CCM (Case Manager Certification) CCM

Managed care experience I.e. Medicare HMO, D-SNP

Motivational interviewing

Bilingual Spanish and English

Physical Requirements

Primary Duty

Percent of Time Performing Duty

Visual Acuity

YES

75-100%

Hearing

YES

75-100%

Standing

YES

75-100%

Walking

YES

75-100%

Lifting/Pulling/Pushing

YES

75-100%

Sitting

NO

0-24%

Reports To: Director of Nursing

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