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Registered Nurse Care Manager
3 months ago
State Licenses:
Valid unencumbered NY & CT State RN License Required. Can allow for small grace period to obtain CT State License.
Position Summary:
The Nurse Care Manager plays a key role in an interdisciplinary team, collaborating closely with the Hospitalist, Post-Acute Care, Primary Care, Social Work, and other care team members to offer Care Coordination services to identified patients throughout the care continuum. By building relationships with patients and families in care transitions and long-term care settings, the Nurse Care Manager enhances the patient experience. Using clinical expertise to identify obstacles, the Nurse Care Manager aims to decrease costs and enhance clinical outcomes by working as a valuable team player, managing specified groups of post-acute and long-term care patients, organizing care through personalized plans focused on linking to primary and specialty care, reducing Emergency Department visits, hospital admissions and readmissions, addressing care gaps, or managing at-risk situations by ensuring comprehensive care coordination. Job responsibilities may involve patient outreach and engagement, coordinating clinical and non-clinical services, conducting assessments, creating care plans, collaborating with external organizations, participating in case conferences, making home visits, offering self-management support, and providing health coaching.
Essential Job functions:
- Collaborates with interdisciplinary care team to facilitate smooth patient engagement and transitions across the care continuum.
- Learns, understands, and carries out the Care Management and Transitions of Care process and workflow effectively.
- Addresses and ensures timely completion of assigned transitions of care tasks (hospital/sub-acute, emergency room discharges) in the EHR/care management platform in accordance with coding guidelines, applying care management principles to assist patients in achieving patient-centered clinical treatment and Transition of Care objectives.
- Acts as a liaison to providers, patients, and families based on established Care Management referral criteria to coordinate services that optimize clinical and financial outcomes, working in collaboration with health plan partners, providers, practice staff, and other healthcare team members to identify suitable patients for care management.
- Conducts comprehensive initial and periodic assessments for the care managed population. Develops and implements clinical care management plans in partnership with the primary care provider, specialist, and other care team members addressing the identified needs of the patient by considering patient/family needs, cultural diversity, health literacy, available resources, and care goals.
- Identifies and efficiently utilizes community resources to meet the needs of patients and families, educates them on available options, prioritizes patients based on intensity and requirements, and schedules follow-up appointments with primary care or a specialty department at Summit Health.
- Crafts a mutually agreed care management plan with the healthcare team and patient/family comprising specific objectives, action-oriented interventions, and self-management goals.
- Monitors patient progress and evaluates the plan's effectiveness in achieving established care goals. Adjusts the plan as necessary to address evolving needs, issues, and goals while communicating the status of care plans with care team members and the patient/family.
- Collaborates with the healthcare team to update the care management plan as needed. Organizes care conferences to discuss interdisciplinary care team responsibilities, patient progress, new issues, and more.
- Records information accurately in the electronic health record, care management platform, and any essential patient tracking documents, ensuring timely and appropriate utilization of the EHR tasking feature. Maintains precise and prompt documentation adhering to current standards and policies.
- Maintains familiarity with Health Plan mandates, fosters cooperative relationships with Health Plan case managers, advocates for patients with third parties to secure cost-effective, quality services, and maximize resource efficiency.
- Exhibits a comprehensive understanding of Health Plan contracts, including patient attribution, care management requirements, clinical quality metrics, and utilization/cost outcomes.
- Proficiently utilizes Health Plan-provided reports and data.
- Strives to meet specified productivity and care management metric standards.
- Routinely reviews utilization and quality reports, identifying care gaps and patients in need of additional care management support.
- Participates in regular team meetings, peer review activities, departmental functions, and organizational committees as required.
- Contributes to the training of new team members, serves as a preceptor and mentor to peers, and encourages collaborative teamwork.
- Establishes relationships across various organizational departments and excels in managing innovative and unstructured situations.
- Performs all care management tasks across the care continuum while upholding patient confidentiality, privacy, safety, advocacy, and compliance with ethical, legal, and accreditation/regulatory standards.
- Provides care management services within the licensed scope following Summit policy.
- Adapts to evolving patient and organizational priorities, demonstrating self-motivation, effective prioritization, and process enhancements to boost efficiency and efficacy.
- Manages conflict, stress, and multiple concurrent work demands adeptly and professionally.
- Pursues continuous education and learning opportunities related to comprehensive primary care and chronic disease management.
- Undertakes any other assigned duties.
General Job functions:
Transitional Care Management:
- Conducts follow-up calls for patients recently discharged from the emergency department or acute hospitalizations and deemed at risk/high risk for admission/readmission.
- Collaborates with providers, healthcare team members, inpatient facilities, health plans, and health system administrators to streamline care transitions and continuity, aiming to optimize clinical and financial outcomes.
- Ensures timely completion of all assigned transitions of care tasks (hospital/sub-acute, emergency room discharges) in the EHR/care management platform, adhering to coding guidelines, and schedules follow-up appointments with primary care or a specialty department at SMG.
Patient Identification and Management:
- Identifies patients based on risk, necessity, cost, planned procedures, care transitions, payer-provided data, referrals from the care team/providers.
- Conducts comprehensive chart reviews considering chronic diseases, risk factors, polypharmacy, functional status, utilization patterns, and social determinants of health.
- Stratifies risk by categorizing patients and populations according to their likelihood of adverse outcomes, precisely predicting health risks and potential service utilization based on current and past healthcare resource use.
- Identifies care gaps and collaborates with the care team through pre-visit chart preparations or morning huddles to plan patient outreach and engagement strategies.
Quality Improvement Initiatives:
- Participates in ongoing quality improvement initiatives to enhance performance and patient outcomes.
- Demonstrates proficiency in compiling patient data and conducting outcome analyses.
- Serves as a knowledgeable resource for existing and upcoming quality improvement endeavors within Summit.
- Proficiently documents chronic HCC codes, HEDIS measures, ensuring data accuracy within the EHR.
Competency, Training and Education:
- Displays understanding of PCMH requirements and standards.
- Capable of executing specific workflows related to Care Management and Transitions of Care.
- Demonstrates effective communication and collaboration with care team members.
- Maintains core proficiencies and competencies as outlined by the Care Management Program.
- Proactively seeks further knowledge on comprehensive primary care and chronic disease management.
- Self-driven, focused, capable of independent work with effective time and task management.
- Establishes productive relationships with internal and external stakeholders.
Education, Certification, Computer and Training Requirements:
- Bachelor's Degree preferred.
- Valid unencumbered NY & CT RN License Required.
- Valid Driver's License required & proof of valid vehicle insurance
- Minimum of 4 years Care/Case Management Experience or similar clinical experience preferred.
- Certified Case Manager (CCM) preferred.
Travel:
- Capable of traveling to various locations.
- Able to work with patients/families in diverse settings, including offices, facilities, and homes, accommodating various physical conditions and social/cultural environments.
Pay Range $90,000 to $105,000
The provided compensation range is determined based on industry standards and considers factors such as experience and position location.
