DaVita RN, Chronic Care Specialist in TORRANCE, California

RN, Chronic Care Specialist


DaVita Medical Group manages and operates medical groups and affiliated physician networks in California, Nevada, New Mexico, Florida, Colorado and Washington in its pursuit to deliver excellent-quality health care in a dignified and compassionate manner. As of June 30, 2016 DaVita Medical Group (formerly HealthCare Partners) provided integrated care management for approximately 760,000 patients. DaVita Medical Group’s leadership development initiatives and social responsibility efforts have been recognized by Fortune, Modern Healthcare, Newsweek and WorldBlu.

We are committed to bringing the benefits of coordinated care to our patients and to taking a leading role in the transformation of the national healthcare delivery system to assure quality, access, and affordable care for all.

If you're looking to make a difference with a large, financially stable, well-recognized medical group, DaVita Medical Group may be the employer for you.


Responsible for the evaluation,education, clinical intervention and chronic care management of those patientswho are identified in need of management within the chronic care clinic. Manages the chronic disease conditions byinitiating a patient centric plan of care that will maximize the patient’s abilityto self manage their disease process using clinical assessment, evaluation, andmotivational interviewing skills to facilitate the continuum of patients’ careutilizing advanced nursing knowledge, experience and skills to ensure patientquality outcomes. Care Managementfunctions will be preformed as part of the clinical team within the clinic andmay be done on-site, telephonically or in the patients’ home.


  • Consistently exhibits behavior and communicationskills that demonstrate HealthCare Partners’ (HCP) commitment to superiorcustomer service, including quality, care and concern with each and everyinternal and external customer.

  • Conducts full assessment of the high risk patient,inclusive, but not limited to assessment of pain, diet, falls, hearing,dentition, urinary and mental status.

  • Assesses patient’s social network, inclusive of alldependencies and support systems.

  • Conducts assessment of home setting to evaluate howthe home environment contributes to the medical and social well being of thepatient.

  • Conducts medication reconciliation anddocumentation findings on plan of care.

  • Uses techniques of motivational interviewing todevelop patient centric plan of care in coordination with the patient andfamily and identifies caregivers.

  • Facilitates and encourages family involvement inall aspects of treatment plan.

  • Participates actively as member of chronic careclinical team to ensure that patients have their needs identified proactivelyand that their plan of care is continuously evaluated and updated as clinicalstatus changes and patient progresses toward goals.

  • Documents pertinent patient information, allcommunication and CM decisions.

  • Provides education and training that align with thepatient needs and willingness to learn.

  • Implements and monitors applicable care managementprograms within the policies and procedures and algorithms set by the CareManagement department, inclusive but not limited to: CHF, COPD.

  • Processes applicable referrals as ordered by theclinician who has oversight of plan of care.

  • Discusses Advanced Care Planning Issues with thepatient and family as part of the clinical team and coordinates and facilitatestransition to palliative care and hospice care if appropriate.

  • Oversees the patient throughout the continuum ofcare when admitted to the acute or skilled facility setting throughconsultation with members of the inpatient team and facilitates movement on atimely basis throughout changes in level of care.

  • Ensures appropriate utilization of medicalfacilities and services within the parameters of the patients’ benefit and/orCMC decisions.

  • Facilitates discharge from facilities by ensuringthat home health, DME and transportation, etc., are initiated in order tomaintain continuity of care through appropriate handoff from the inpatientteam.

  • Communicates authorization or denial of services toappropriate parties. Communication mayinclude patient (or agent), attending/referring physician, and referred tophysician or facility as appropriate.

  • Demonstrates a thorough understanding of the costconsequences resulting from care management decisions through utilization ofappropriate reports such as Health Plan Eligibility and Benefits, Division ofResponsibility (DOR), and Bed Days.

  • Maintains effective communication with the healthplans, hospitals, extended care facilities, patients, families and the chroniccare team, including social workers and physicians and includes patient andfamily in all care decisions.

  • Provides accurate information to patients andfamilies regarding HMO benefits, community resources, referrals and otherrelated issues.

  • Initiates and/or oversees data entry into ISsystems of all patients within the parameters of Care Management policies andprocedures. Maintains accurate andcomplete documentation of care rendered including LOC, CPT code, ICD-9,etc.

  • Documents all interactions with patients includingassessment and plan of care updates.

  • Adheres to Universal Precautions at all times.

  • Adheres to safety policies and procedures at alltimes.

  • Uses, protects, and discloses HCP patients’protected health information (PHI) only in accordance with Health InsurancePortability and Accountability Act (HIPAA) standards.

  • Performs additional duties as assigned.



  • Bachelor’s degree from a four-year college and/or aprofessional certification requiring formal education beyond a two-yearcollege.

  • Graduation from an accredited school of Nursing.

  • California RN license.

  • Basic Life Support for Healthcare providers (AHA)or CPR/AED for the Professional Rescuer (American Red Cross).

  • Bachelor’s degree in Nursing preferred.



  • Over 3 years and up to and including 5 years ofclinical experience where use of clinical knowledge, assessment and evaluationskills are utilized.


  • Acutenursing experience in critical care.

  • Previouscare management or discharge planning experience.

  • HMOexperience.


  • Computer literate.

  • Ability to type 25 wpm.

  • Knowledge of current standards of patient care.

  • Thorough understanding of RN scope of patient care.

  • Manual dexterity to use/handle equipment andinstruments.

  • Ability to effectively communicate and collaboratewith physicians, patients, families and ancillary staff.

  • Ability to make sound, independent judgments andact professionally under pressure.

Primary Location CA-TORRANCE - 90503

Req ID: 301912