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Acute Nurse Case Manager

2 months ago

Orlando FL United States ChenMed Full time

We’re unique.  You should be, too.

We’re changing lives every day.  For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts?  Do you inspire others with your kindness and joy?

We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

The Acute Nurse Case Manager is responsible for achieving positive patient outcomes and manage quality of care across the continuum of care. The incumbent in this role will, first and foremost, serve as an advocate for our patients. He/She will work with other members of the care team to develop effective plans of care and high levels of care coordination. This care planning and coordination may follow the patient from our centers into acute and post-acute facilities, as well as their home environments. The Nurse Case Manager 2 (RN) will also establish key relationships with patients’ families and care givers, primary care physicians, specialists, other care providers, social workers, other case managers and nurses, acute and post-acute facilities, home health care companies, and health plans. He/She will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures.

CORE JOB DUTIES/RESPONSIBILITIES:

  • Manage and plan for transitions of care, discharge and post discharge follow up for patients admitted to key high volume/high priority hospitals.
  • Collaborate with clinical staff in the development and execution of the plan of care and achievement of goals.  Report variations to PCP/ transitional care physicians (TCP) and implement actions as appropriate.
  • Build relationships with preferred acute care providers (hospitalists, specialists).
  • Direct referrals to preferred providers.
  • Coordinate the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting. Coordinate the patient care, discharge, and home planning processes with hospital case management departments, and other healthcare facilities.
  • In conjunction with the PCP, hospitalist, TCP, insurance case manager and the hospital case manager, coordinate the patient transition to the appropriate/least constrictive level of care using a preferred provider.
  • Keep the PCP aware of patient condition via e-mail, DASH, HITS or other appropriate means of communication.
  • Introduce self to patient/family and explain nurse case manager role and process to contact nurse case manager for questions, guidance and education.
  • Provide high intensity engagement with patient and family.
  • Facilitate patient/family conferences to review treatment goals, optimize resource utilization, provide family education and identify post-hospital needs.
  • Enhance a collaborative relationship to maximize the patient’s/family’s ability to make informed decisions. 
  • Address advanced care planning including treatment goals and advance directives.
  • Refers cases to social worker (hospital and JenCare) for complex psychosocial and economic needs.
  • Reports observed or suspected child or adult abuse pursuant to mandated requirements.
  • Obtain onsite and EMR access at priority facilities.
  • Maintain clinical and progress notes for each patient receiving care and provide progress report to PCP and others as appropriate.
  • Submit required documentation in a timely manner and in appropriate computer system.
  • Assists with quality audits and data analyses to identify opportunities for improvement.
  • Supports quality improvement initiatives.
  • Assists with creation and implementation of SOPs.
  • Assists with coverage for PTO and open positions as requested.
  • Serves as a preceptor when assigned.
  • Serves as a resource for CM/DM process and documentation.
  • Provides supervisory coverage for the Lead Case Manager as needed.
  • Assists with patient complaints and follows to resolution.
  • Participate in surveys, studies and special projects as assigned.
  • Attends meetings as assigned
  • Performs other duties as assigned and modified at manager’s discretion.

There are 4 Nurse Case Manager II Roles with Additional Essential Job Functions:

Acute Case Manager (primarily hospital based)

Responsibilities include all the above “Core” duties/responsibilities plus the following:

  • Coordinate the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting. 
  • Coordinate the patient care, discharge, and home planning processes with patient/family, insurance case managers and hospital case management departments, and other healthcare facilities.
  • In conjunction with the PCP, hospitalist, TCP, insurance case manager and the hospital    case manager, coordinate and communicate the timely patient transition to the most appropriate/least restrictive level of care using a preferred provider.
  • When patient in SNF, in conjunction with the post-acute physician, coordinate the transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed.
  • Validate appropriateness of inpatient vs. observation status. 
  • Facilitate discharge to appropriate level of care and preferred providers.
  • Coordinate acute UR physician meetings.

Transitional Case Manager (Blended Acute and Community Case Manager Roles)

Responsibilities include all the above “Core” duties/responsibilities plus the following:

  • Acute and Community Case Manager roles as above.
  • Onsite patient visitation, risk assessment, and care coordination in the acute and community settings.
  • Discharge needs assessment and planning.
  • Assist patient with engaging community resources.
  • Post discharge telephone calls with medication reconciliation.
  • Post discharge follow up appointment scheduling.
  • Home visits with case management assessment including risk and needs assessments.
  • Ongoing monitoring of high risk patients with select conditions (congestive heart failure, chronic obstructive pulmonary disease, etc.)
  • Multidisciplinary case conferences.

KNOWLEDGE, SKILLS AND ABILITIES:

  • Proven working experience in case management.
  • Excellent knowledge of case management principles, healthcare management and reimbursement.
  • Effective communication skills.
  • Excellent organizational and time management skills.
  • Familiarity with professional and technical emerging knowledge.
  • Problem solving skills and ability to multi-task.
  • Compassionate with teamwork skills.
  • Skill in the analysis and re-engineering of systems, processes, and procedures.
  • Ability to develop, implement, and modify multidisciplinary health care plans.
  • Familiar with standard concepts, practices, and procedures within a particular field. Relies on extensive experience and judgment to plan and accomplish goals.
  • Proficient in Microsoft Office Suite products including Excel, Word, PowerPoint and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software.
  • Ability and willingness to travel locally, regionally and nationwide up to 10% of the time.
  • Spoken and written fluency in English.
  • Bilingual preferred.
KNOWLEDGE, SKILLS AND ABILITIES:
  • Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
  • Critical thinking skills required.
  • Ability to work autonomously is required.
  • Ability to monitor, assess and record patients’ progress and adjust and plan accordingly.
  • Understanding utilization review and how to leverage with inpatient staff for possible reduction of medical cost on long length of stay patients.
  • Ability to plan, implement and evaluate individual patient care plans.
  • Knowledge of nursing and case management theory and practice.
  • Knowledge of patient care charts and patient histories.
  • Knowledge of clinical and social services documentation procedures and standards.
  • Knowledge of community health services and social services support agencies and networks.
  • Organizing and coordinating skills.
  • Ability to communicate technical information to non-technical personnel.
  • Proficient in Microsoft Office Suite products including Excel, Word, PowerPoint, and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software.
  • Ability and willingness to travel locally, regionally, and nationwide up to 10% of the time.
  • Spoken and written fluency in English, bilingual preferred.
  • Associate degree in Nursing required.
EDUCATION AND EXPERIENCE CRITERIA:
  • Bachelor’s Degree in nursing (BSN) or RN with bachelor’s degree in a related clinical field preferred.
  • A valid, active Registered Nurse (RN) license in State of employment required.
  • A minimum of 2 years’ clinical work experience required.
  • A minimum of 1 year of utilization review and/or case management, home health, hospital discharge planning experience required.
  • A minimum of 1 year of case management experience in acute case management or community case management experience highly desired.
  • This position requires possession and maintenance of a valid driver's license.
  • Certified Case Manager certification is preferred. Certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN) desired.

We’re ChenMed and we’re transforming healthcare for seniors and changing America’s healthcare for the better.  Family-owned and physician-led, our unique approach allows us to improve the health and well-being of the populations we serve. We’re growing rapidly as we seek to rescue more and more seniors from inadequate health care. 

ChenMed is changing lives for the people we serve and the people we hire.  With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow.  Join our team who make a difference in people’s lives every single day.

Current Employee apply HERE

Current Contingent Worker please see job aid HERE to apply