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Population Health Long Term Care Case Manager RN, Bakersfield, CA

Organization: Kern Health Systems
Category: Nurse
Location: Bakersfield, CA
Date Job Posted: February 7, 2024
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Population Health Long Term Care Case Manager RN

Kern Family Health Care, 2900 Buck Owens Blvd., Bakersfield, California, United States of America Req #2237

We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization. Qualified applicants are considered for positions without regard to race, color, religion, sex (including pregnancy, childbirth and breastfeeding, or any related medical conditions), national origin, ancestry, age, marital or veteran status, sexual orientation, gender identity, genetic information, gender expression, military status, or the presence of a non-job related medical condition or disability (mental or physical).

KHS reasonably expects to pay starting compensation for the position of Population Health Management Long Term Care Case Manager RN in the range of $41.08 – $53.27 hourly.

Our Mission.. Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system.


Under direction of the Kern Health Systems (KHS) PHM LTC CM RN is responsible for providing complex case management (CCM) specific to the Seniors and Persons with Disabilities (SPDs) and Medicaid populations residing in the LTC facility. Complex case management within KHS is defined as the coordination of care and services for members who need help navigating the healthcare system to facilitate the appropriate delivery of care and services. These services are provided utilizing available resources across a continuum of care and in collaboration with members, caregivers, medical home providers, and ancillary health care providers.


Incumbents in this position are fully competent in all essential areas of basic and complex case management and are expected to use an advanced level of judgment in the discharge of their duties. Case Managers work independently under general direction. This position involves frequent communication with members, caregivers, medical providers, and KHS staff telephonically, electronically and potentially in-person.


Essential Functions

  • Is the primary case manager.
  • Compiles and reviews member profile and related records (i.e., demographics, medical history, medications, etc.).
  • Contacts members to explain the program to members and/or caregivers (i.e. benefits and services) and obtains consent for services (if needed).
  • Comprehensively assesses and documents the member’s medical and psychosocial needs, identifying the individual’s strengths and needs, and gaps in care.
  • Determines and assigns patient acuity level of care.
  • Develops and implements a Plan of Care (POC) based on the assessments and level of care.
  • Reviews member progress and conduct reassessments of POC quarterly or as needed.
  • Conducts site visits to facilities
  • Acts as a facilitator and/or advocate for the member in dealing with issues with providers, community programs or other organizations.
  • Acts as a gatekeeper to ensure that the member is receiving the most appropriate, cost-effective services in the most appropriate setting.
  • Appropriately assigns/refers to ancillary support staff such as the PHM Social Workers and/or Case Management Assistants (CMA).
  • Obtains copy of Form 157 from members
  • Presents and actively participates in meetings such as Interdisciplinary Care Team (ICT), department and facility meetings.
  • Collects, compares, and analyzes data; identifies trends; and addresses gaps in services; maintains records and prepares reports.
  • Documents all care plan notes in accordance with professional standards in a thorough and timely manner.
  • Identifies and refers quality of care, coordination of benefits, and third-party liability issues as appropriate.
  • Recognizes members’ right to participate or refuse treatment.
  • Communicates, consults and collaborates with KHS Medical Director on an as needed basis.
  • Serves as a liaison to community providers and KHS Members.
  • Collaborates with KHS staff to facilitate production of reporting necessary to obtain statistics to monitor, establish and identify member care needs.
  • Provides written and verbal communication with contract providers and KHS staff to promote appropriate and timely coordination of care.
  • Participates and acts as a resource to the Fraud Waste & Abuse Committee
  • Resources to the Grievance Committee for Complex Members.
  • Performs other job-related duties as assigned.


Core Competencies/Knowledge & Skill Requirement

  • Leads by example to support a positive work environment that values patient advocacy, respectful listening, diverse expression of opinion and constructive conflict resolution;
  • Adheres to KHS’s Code of Ethics and Business Conduct and all company policies; e.g., confidentiality, attendance, safety/security, use of equipment and technology, appearance and demeanor;
  • Demonstrate knowledge of Population Health Management, social determinants of health and health equity.
  • Represent KHS in a positive manner to all members, caregivers, staff and external stakeholders.
  • Demonstrate commitment to continuous improvement;
  • Strong knowledge of acute chronic care nursing principles, methods and common treatments;
  • Strong knowledge of common human diseases and usual and customary methods of treatments;
  • Demonstrated knowledge of medical terminology;
  • Ability to effectively evaluate medical records to determine appropriateness and necessity of care;
  • Demonstrated knowledge of health care delivery systems;
  • Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individual at all levels both inside and outside of KHS;
  • Ability to use tact and diplomacy to diffuse emotional situations;
  • Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards.
  • Intermediate skills in Word and Excel with basic ability to enter data into and navigate through a database.
  • Demonstrated ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, KHS business or employee information and make no disclosure of such information except as required in the conduct of business;
  • Demonstrated ability to commit to and facilitate an atmosphere of collaboration and team work;
  • Self-directed, with proven ability to work independently with minimum supervision;
  • Demonstrated ability to multi-task in an interrupt-driven environment and complete assignments on a timely basis;
  • Strong attention to detail; work accurately and at a reasonable rate of speed;
  • Compliant with KHS policies and procedures; performs the job safely and with respect to others, to property, and to individual safety.


Education and Experience:

  • Registered Nurse with an active, current, unrestricted California license
  • Minimum of two (2) years full-time clinical experience in acute care, community health setting, public health nursing or chronic disease management required;
  • Experience working with patients and caregivers regarding self-care and disease management required;
  • Experience working in case management or care coordination is a plus;
  • Knowledge of Kern County Community resources for seniors and people with disabilities is a plus;
  • Bachelor’s Degree in Nursing from an accredited school or equivalent, Health Administration or related healthcare field preferred.


  • Possession of valid driver’s license and proof of State required auto liability insurance. Required Travel Up to 5%
  • Bilingual (English/Spanish) preferred

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis.

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