• Performs duties and responsibilities 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.
• Performs authorized nursing and care management services in participant home , as needed e.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. Identify patterns of overuse or underuse of services and take corrective actions as needed.
• Monitor health outcomes and the effectiveness of care plans to ensure that services provided are leading to desired health improvements. Use data and analytics to identify opportunities for improving care delivery and reducing unnecessary utilization.
• Conducts home care assessments and creates home care orders with tasks for ADLs and IADLs. Obtains and ensures that home care order is co-signed by Primary Care Provider prior to delegating service coordination to the Home Care Coordinator, LVN.  
• Updates care plans with home care intervention plan and progress notes. Documents service outcomes in participant electronic medical record. Collaborates with Home Care, LVN ensuring that home care records from subcontracted agencies are requested and uploaded to the participants’ electronic medical record in a timely manner.  
• Maintains complete medical records, with thorough documentation  and maintains confidentiality of participant information in Electronic Health Record system.

Qualifications

• Valid and active CA RN license.
• Proficiency in Mandarin and/or Cantonese strongly preferred.
• 5+ years of RN experience.
• 2+ years care management/transitions in care experience, preferably in a geriatric care setting.
• Influential communication skills; capable of conducting care management conversations with Seen Health participants and their families.
• Strong documentation skills.

1. Salary: $120K - $145K / year
2. Equity: included as part of founding team package
3. Benefits: Seen Health is proud to offer a robust benefits offering for our employees. In addition to traditional healthcare coverage, we also offer additional benefits to help further your wellness and feeling of being part of the team.
   • Medical, Dental, and Vision benefits for you and your family
   • Life Insurance and Disability Benefits
   • Parental and Caregiver Leave
   • Lunch, as well as delicious snacks and coffee to keep you energized
   • Paid Time Off across holidays, vacation time, personal days, and sick days
   • 401k Plan
   • Personal and professional development, including CME support and career growth opportunities
   • Subscriptions and training on using AI tools including ChatGPT