BSN or MSN Required Join Alameda Health System's Nursing Team!Strategic Direction for Our Nursing Team: Patient Focused Care - Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs. Enhanced Collaboration and Interdisciplinary Teamwork - Create an environment that allows the collective knowledge, resources and skills of each team member to flourish. Clinical Scholarship and Professional Development - Promote evidenced-based practice in the clinical setting and to create an environment for advanced education and enhanced clinical expertise. Innovation and a Culture of Discovery - Design and implement new and innovative processes that drive continuous performance improvement. Shared Governance and Professional Accountability - Promote an environment in which clinical staff have a voice in determining their practice, standards and quality of care, and are willing to take 100% responsibility for their practice, patient care quality and outcomesJob Summary:Responsible for providing comprehensive case management services to clients identified with complex health conditions and social challenges that are at risk for health status decline.The goals and focus of these service efforts are to provide timely delivery of intensive case management services during the transitional period beginning with hospitalization and culminating with integration back into the community setting to prevent further health deterioration and reduce the need for more costly services such as acute care hospitalization and to develop self-management skills that improve his or her long-term health status.Incumbent performs all duties and responsibilities according to the Reducing Readmission Project policies and procedures, complying with established standards of care and contract requirements specified with the Moore Foundation Grant, and in accordance with the values of the organization.Performs related duties as required.Qualifications: Education:Bachelor's Degree in Nursing or related field, Master's degree in Nursing or health related field preferred. Minimum Experience:One to three years acute care experience a plus.Varied clinical experience or experience in case management/community health a plus. Required Licenses/Certifications:Valid license to practice as a Registered Nurse in the State of California.Required Licenses/Certifications:BLS ? Basic Life Support Certification issued by the American Heart Association.Valid California Driver's License. Preferred Licenses/Certification:Public Health Nurse, Case Management, Home HealthKnowledge, Skills & Abilities: Act in an appropriate and professional manner as defined by the company's Standards of Behavior, Policy and Procedures, and Scope of Services. Role model ACMC Standards of Behavior. Proficient computer skills including Microsoft Office (Word, Outlook, Excel, PowerPoint). Current office administrative practices and procedures Correct business English, including spelling, grammar and punctuation Use independent judgment and initiative within established policies and procedures. Establish and maintain effective working relationships with a variety of individuals from various socioeconomic, ethnic and cultural backgrounds. Knowledge of wellness to illness continuum. Working knowledge of public health, community resources and case management principles.Working knowledge of state and federal medical and social benefits. Self directed work, requiring good problem-solving and sound clinical judgment is required. Works in collaboration with physicians, staff, social work and other disciplines. Professional nursing practice, attitude and mission. Communicates effectively with patients and hospital personnel in person, by phone and in writing. Broad based clinical knowledge of specialty and acute care Ability to assist clients with basic financial management skills. Ability to perform a variety of duties dealing with people, often changing from one task to another without loss of efficiency or composure. Demonstrates interest in and ability to assume leadership role. Willingness to be flexible with work schedule.Job Responsibilities:1.Interprets and explains procedures, regimens, and services to patients and families; teaches patients and family member's health care and disease prevention techniques.Participates in promoting a healthful, safe, and therapeutic environment for patients and families, set up and controls the environment essential for infection control.2.Communicates with physicians and multidisciplinary health team members to provide continuity of care, supporting and maintaining the multidisciplinary team approach to ensure effective resource utilization; documents as needed in the patient medical record.3.Monitors care provided making suggestions to achieve optimal outcomes, based on evidence base practice.Participates in outcome data monitoring and audits as needed.4.Utilizes concepts of assessment, education, health coaching and provide patient-centered services.Organizes, prioritizes and completes activities and assignments in an efficient manner.5.Utilizes daily hospital census reports to identifying current and potential clients.Assesses potential clients using the designated tools and initiates hospital-based coaching activities/interventions as appropriate and in coordination with hospital staff.6.Acts as a liaison with primary care providers for identified groups of hospitalized clients.Maintains close working relationships with identified community-based providers.Visits clients/potential clients in both hospital and community settings, including private homes.Provides own transportation to community based visits.7.Responsible for direct service provision including enrollment into CTP, care coordination and evaluation of care plan.8.Obtains signed consent form for client participation and for release of information from client, and initiates Care Plan.In conjunction with the Care Transitions Program team, teaches, supervises, and counsels the client and identified support system regarding the care plan.Delivers delegates and/or supervises individual client interventions, including care coordination and evaluation of outcomes.9.Provides disease management education and coaching, focusing on individual client self-management principles.This includes medication reconciliation, development of a person health record, preparing for provider visits and community resource.Makes appropriate recording of interventions and client progress, and reports patient status to CTP team regularly.10.At times, supervises Student Nursing Interns and/or Medical Assistants.11.Reassesses the client's condition when changes occur and revises the care plan as appropriate.Coordinates and arranges for needed services with appropriate local resources.Serves as patient advocate to secure services and financial benefits.12.Promote health care along the continuum of services, decreasing care fragmentation through care coordination with other community providers, enhancing the client's quality of life by improving access to services and preventing inappropriate institutionalization and providing cost-effective service planning.13.Serves as a mentor and educator to the other members of the Alameda County Health Center healthcare team assisting with care coordination, training, and quality improvement activities.Posted by StartWire..