Founded in 1970, East Valley Community Health Center is a Federally Qualified Health Center (FQHC) who's services include providing personalized, affordable, high-quality medical, dental, vision and behavioral health care through a community-based network within the East San Gabriel Valley and Pomona Communities. Our staff practices patient-centered care by serving each patient with a personalized care plan that meets their individual needs. Our patients have access to support services that include, nutrition, health education, case management, pharmacy, lab, and x-ray at our health center locations. East Valley serves the health care needs of uninsured and underserved individuals and families throughout our 8 health center locations.
Our mission is to provide access to excellent health care while engaging and empowering our patients, employees, and partners to improve their well-being and the health of our communities.
Position Purpose:
The Care Manager provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across settings and helps patient/families understand health care options. Manages a caseload of approximately 200 complex patients.
Major Position Responsibilities and Functions:

• Identifies the targeted high risk population within practice site(s), per PCP/Care Team referral, risk stratification, and patient lists.
• Assesses over time the healthcare, educational and psychosocial needs of the patient/family. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.
• Collaborates with PCP/Care Team, patient and members of the health care team, including continuum of care settings and community. Responsible for developing a comprehensive individualized plan of care and targeted interventions. Continually monitors patient/family response to plan of care, and revises the care plan as indicated.
• Provides self-management support with focus on empowering the patient/family to build capacity of self-care.
• Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.
• Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
• Coordinates patient care through ongoing collaboration with PCP, patient/family, and other members of the health care team. Fosters a team approach and includes patient/family as active members of the team. Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries. Serves as liaison to acute care hospitals, specialists, and post-acute care services.
• Provides follow-up with patient/family when patient transitions from one setting to another. Completes timely post-hospital follow-up: Medication reconciliation, PCP or specialist follow-up appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.
• Maintains required documentation for all care management activities.
• Works with care teams and leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance the Patient Centered Medical Home delivery of care model.
• Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.
• Participates in multidisciplinary care team meetings, as required.
• Other assigned duties as directed.

Required Qualifications:

• Current Registered Nurse License
• Two years of experience with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical, within the past five years.
• Knowledge of chronic conditions, evidence based guidelines, prevention, wellness, health risk assessment, and patient education.
• Critical thinking skills and ability to analyze complex data sets. Ability to manage complex clinical issues utilizing assessment skills and protocols.
• Excellent assessment and triage skills. Ability to implement evidence base interventions and protocols for chronic conditions.
• Demonstrates excellent communication-both verbal and written.
• Excellent interpersonal and facilitation skills.
• General computer knowledge and capability to use computers.
• Must relate well to all cultural and ethnic groups in the community.
• Bilingual in English and Spanish, preferred.

Benefits:
East Valley offers a competitive salary, paid holidays, PTO, and 403b retirement plan. East Valley matches the first 6% and you are fully vested immediately! You will also enjoy work-life balance with paid time off and paid holidays throughout the year.
Please apply to this position with your current resume.
Principals only. Recruiters, please do not contact this job posting.

EOE is the Law. It is the stated policy of EVCHC to conform to all the laws, statutes, and regulations concerning equal employment opportunities and affirmative action. We strongly encourage women, minorities, individuals with disabilities and veterans to apply to all of our job openings. We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, gender identity, or national origin, age, disability status, Genetic Information & Testing, Family & Medical Leave, protected veteran status, or any other characteristic protected by law. We prohibit Retaliation against individuals who bring forth any complaint, orally or in writing, to the employer or the government, or against any individuals who assist or participate in the investigation of any complaint or otherwise oppose discrimination.

Job Type: Full-time

Pay: $42.50 - $56.25 per hour

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