RN Case Manager - California

At ConcertoCare, we believe seniors and older adults with complex care needs deserve a more holistic, equitable, and compassionate approach to health and wellness. ConcertoCare is a provider of team-based, at-home care focused on seniors and other adults. Our goal is to take a human-first approach to orchestrate care for the country’s most medically complex patients. We know that providing care for loved ones requires trusted partners—we’ve redefined how we manage and deliver at-home care, and our company culture reflects our mission-driven team that’s committed to providing compassionate, quality care to our patients.

The ConcertoCare Case Manager coordinates all aspects of a patient’s care (medical, behavioral, functional, and social) and serves as a patient advocate across the continuum of care in partnership with the patient’s providers and extended care team. This is a unique Case Management role that is intimately integrated with a larger care team. This role requires a high level of interaction to successfully engage patients and foster positive, trusting relationships to help them achieve their goals. The ideal Case Manager has excellent communication skills, takes initiative, works well with other members of the care team, and creatively solves problems to address a patient’s needs holistically. This position is part of the Population Health Team, reports to the Vice President of Case Management, and works closely with other Population Health team members as well as market-based care teams. This is an ideal position for a registered nurse who seeks an opportunity to contribute to the health and well-being being of highly complex patients, enjoys a collaborative multidisciplinary team-based approach to care, and is excited to engage in developing and nurturing our innovative, value-based clinical model focused on caring for patients with complex and social support needs that the current health system does not serve well.

Conduct initial intake calls as well as scheduled and urgent patient outreach based on individual patient’s needs and risk levels to review and update the care plan, monitor progress, ensure needs are met, and identify new areas of concern. Provide ongoing care coordination for an assigned panel of complex patients. Conduct needs assessments and develop plans of care in partnership with the rest of the patient’s care team. Ensure care is coordinated, patient-centered, and aligned with the needs and wishes of the patient. Support patients during care transitions, including outreach and assessment during and post hospitalization to ensure discharge needs are addressed, to facilitate provider follow-up, and to perform medication reconciliation. Identify and implement interventions and collaborate closely with ConcertoCare’s multidisciplinary team (providers, Director of Clinical Care, social work, behavioral health, and clinical pharmacy), external providers, and social service organizations to: (1) address gaps in care, (2) mitigate the risk of inpatient admissions, readmissions, emergency room visits and movement to an institutional setting, (3) and keep patients safely living in their desired and appropriate home environment. Identify and verify appropriate utilization of resources across the continuum of care. Actively participate in interdisciplinary care team huddles, and other clinical meetings. Participate in quality improvement and evaluation processes. Adhere to compliance policies, procedures, and standards of conduct including all applicable laws and regulations. Serve as a mentor for new hires and existing case management team members Other duties as assigned.