RN Case Management

About Seen Health At Seen Health, we are revolutionizing the way senior care is delivered through the PACE (Programs of All-Inclusive Care for the Elderly) model. Backed by top VCs, Seen Health is a culturally-focused, technology-enabled healthcare organization that integrates comprehensive medical care and social support with a high-touch, interdisciplinary approach. Our mission is to empower seniors to age-in-place with dignity and provide their families peace of mind.

We are building upon a proven Home and community based services model to create a culturally-competent and scalable PACE program. We are also building a comprehensive operating system focused on data and workflows that span across systems, processes, people, and care contexts. We want to empower our clinicians and staff with tools that deliver relevant data at the time and site of care and enable them to deliver exceptional care to our participants, which improve clinical outcomes, participant & provider satisfaction, and ultimately our strength as an organization.

We are a mission-driven, multidisciplinary team with deep healthcare, technology, and operations expertise, each inspired by our own personal stories of caring for seniors in our lives. Our name, Seen Health, was chosen to reflect our commitment to provide the highest standard of care to underserved older adults while respecting and incorporating their individual beliefs, heritage, and values, so that they can truly be seen .

About The Role

The role of the RNCM is critical to ensure comprehensive and coordinated care that appropriately addresses the complex care needs of frail and elderly PACE participants. The role encompasses interdisciplinary care coordination, robust transition in care coordination, assessments, care planning, implementation, and evaluation of evolving participant care needs to promote optimal health outcomes and improved quality of life.

Responsibilities

Performs duties and

maintaining compliance with regulatory

Requirements

, Seen Health policies and procedures and quality improvement initiatives. Collaborates with Medical Director, primary care providers, clinic manager, and the interdisciplinary team (IDT) to coordinate care across different care settings, ensuring that IDT maintains oversight of participant care and to ensure that participants receive necessary services (medical, social, supportive). Facilitates access to community care.

Performs participant advocacy and maintains daily communication with facility based providers. Facilitates informed decision-making , ensuring that IDT receives timely notifications regarding the health status of participants. Collaborates with IDT to coordinate timely discharge planning, ensuring that participants are discharged to home as soon as possible.

Arrange follow-up care after hospitalizations or changes in health status, including PCP f/u appointments. Provides education to participants, caregivers and family members regarding care transitions, upholding standards for informed consent. Provides end of life support, as needed, managing symptoms for patients receiving palliative care and providing comfort measures and emotional support to participants and families.

Coordinates timely Home Health nursing interventions based on primary care provider (PCP) orders. Requests home health records from subcontracted providers and uploads records of completed services in the participants’ electronic health record. Communicates service outcomes to IDT , ensuring that the PCP and IDT maintain oversight of participant care.

g. wound care, vaccine or medication administration, etc. Completes Utilization Management activities, including but not limited to tracking utilization of hospital admissions, emergency room visits, and specialist consultations.