This is not a remote position, the nurse care manager will be required to make visits to client's homes, attend doctor appointments with them and occasionally come to the office in downtown Yorba Linda

The Nurse Care Manager is a health and human services specialist who acts as a guide and advocate for families who are caring for older relatives or disabled adults. The Nurse Care Manager is educated and experienced in fields related to aging life care / care management, including a specialized focus on issues related to aging and elder care. The Nurse Care Manager will provide professional insight to clients in their homes. This involves coordinating client status through comprehensive care planning on a weekly basis. Nurse Care Manager collaborates with and ensures that doctors’ orders are followed, supports family decision-making, monitors medications, surveys physical activity and safety in the home, along with psychological behavior. Nurse Care Manager supports clients through a holistic, client-centered approach. Nurse Care Manager will support families through guidance leading families to the actions and decisions that ensure quality care and an optimal life for client through: assessment and monitoring; planning and problem-solving; education and advocacy; and family caregiver coaching.

¨ Reports to Director of Care Management

¨ In-home Nurse visits with client

¨ Development of comprehensive plan of care following thorough assessment of physical, functional, and psycho-social status

¨ Provide hospital/facility visits when as needed

¨ Facilitating conference calls between the client and family as needed to clarify treatment plans

¨ Attend physician appointments and facilitate communication between doctor, client, and family

¨ Interact with the health care system effectively and frequently

¨ Reconciling prescribed medication

¨ Assessing client’s environment, functional, psycho-social status and financial well-being

¨ Identifying and developing action plans to empower clients to remain and thrive at home

¨ Help families adjust, cope and problem-solve around long-distance and in-home caregiving

¨ Connecting clients and their families with medical, legal, housing, insurance and financial issues

¨ Coaching clients to manage their health and well-being

¨ Completing required paperwork and documentation within the time frame required

¨ Strategic and analytic thinking to address gaps in care

¨ Help determine types of services including home health and hospice that are right for client and assist in engaging and monitoring those services

¨ Reviewing financial management or consulting with a client’s accountant or Power of Attorney

¨ Help clients and families with insurance concerns, claims, and applications

¨ Assist client and families identify local resources as needed

¨ Provide effective advocacy for clients and their families, promoting the client’s wishes with health care and other providers, ensuring that client’s needs are being adequately addressed

¨ Refer to legal experts, elder law attorneys, estate planners as needed

¨ Provide crisis intervention as needed, supporting clients navigate through emergency departments and hospitalizations, rehabilitation stays, ensuring that adequate care is available to the client

¨ Provides continued ongoing assessment to support clients in attaining their maximum functional potential

¨ Promotes individual independence through encouragement, maintaining safety and security concerns.

¨ Perform other duties as requested by Director of Care Management

¨ Knowledge of health care policies.

¨ Knowledge of medical ethics.

¨ Knowledge of quality assurance techniques.

¨ Knowledge of written and verbal communication techniques.

¨ Knowledge of effective teamwork techniques.

¨ Knowledge of interpersonal sensitivity techniques.

¨ Knowledge of leadership techniques.

¨ Knowledge of management planning techniques.

¨ Knowledge of problem-solving techniques.

¨ Knowledge of decision-making techniques.

¨ Knowledge of time management techniques.

¨ Knowledge of stress management techniques.

¨ Knowledge of prioritizing techniques.

¨ A wide degree of creativity and latitude is expected.

¨ Ability to demonstrate effective interpersonal relations.

¨ Ability to effectively communicate orally and in writing.

¨ Ability to utilize strong clinical and psycho-social assessment skills

¨ Ability to gain respect and cooperation.

¨ Ability to inspire and motivate Home Care Partners and Agency Caregivers

¨ Ability to direct work groups toward a common goal.

¨ Ability to oversee the work of Home Care Partners.

¨ Ability to plan and organize work.

¨ Ability to resolve conflict.

¨ Ability to administer policies and implement procedures.

¨ Ability to identify problems and determine effective solutions.

¨ Ability to work independently and in cooperation with others.

¨ Ability to provide advice and consultation to others.

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¨ Good physical and mental health.

¨ Mental fortitude and stability to handle stress.

¨ Physical and mental ability to drive a vehicle

¨ Nursing Degree and Registered Nurse Licensure/Licensed Vocational Nurse

¨ Current Driver’s License

¨ Proper Vehicle Insurance Coverage

¨ Licensed Nurse with at least one year of post graduate case management experience

¨ Complex Care Management/Case Management/Managed Care experience

¨ Community-based or In-Home visit experience

¨ Experience working with either Geriatric, chronically ill or functionally challenged populations

¨ Computer skills and resources:

¨ Ability to use a variety of electronic information applications/software programs, electronic medical records experience

¨ Intermediate to Advanced computer skills and proficiency with Microsoft Word, Outlook, and Excel, and web navigation skills

¨ Access to a secure computer in order to accommodate data entry within required timelines

¨ Access to High-speed internet connectivity

¨ Valid driver’s license, car insurance, and access to an automobile for home visits to client is required