Bilingual Case Manager, Spanish Speaking
Pair Team
Hybrid RN Care/Case Manager
CenterWell Senior Primary Care
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteSalary
💰 $71,100 - $97,800 per year
Job Level
Mid-LevelSenior
About the role
- Conduct Transitions of Care Management for a subset of the patient population, including hospital, obs, and post-acute care follow ups
- Provide triage guidance and supportive consultation to other team members, handling escalated complex cases
- Develop care plans leveraging 5Ms Geriatric best practice framework
- Develop a wholistic view of patient needs related to Social Determinants of Health
- Identify existing barriers to engagement with necessary resources and supports
- Provide education around maintenance of chronic health conditions, as well as available options for behavioral care and social support
- Serve as liaison between the patient and the direct care providers, assisting in navigating both internal and external systems
- Initiate care planning and subsequent action steps for high-risk members, coordinating with interdisciplinary team
- Supporting patients’ self-determination, motivate patients to meet the health goals they have identified
- Refer patient to necessary services and support across the interdisciplinary team
- Lead Interdisciplinary CIT Team Meetings when indicated
- Assess patient’s family and caregiver system, and conduct family meetings with patient and family when needed
- Participate in creation and facilitation of team training content
- Participate in and lead CIT interdisciplinary review of and coordination around complex patients
- Maintain patient confidentiality in accordance with HIPAA
- Document patient encounters in medical record system in a timely manner
- Follow general policies related to fire safety, infection control and attendance
- Perform all other duties and responsibilities as required
Requirements
- Registered Nurse (RN) license in Texas
- Minimum of 4 years of experience working in healthcare services and navigating community-based resources
- Experience working in care/case management
- Bilingual in English and Spanish with the ability to speak, read and write in both languages
- Prior value-based care experience and working with complex Senior populations
- Experience working effectively within interdisciplinary teams
- Valid state driver's license, reliable transportation, and insurance
