RN Care Manager

Job Summary:

Working in collaboration with Spectrum providers, community health workers, case managers, behavioral health consultants, specialty care practices, health plan staff, home health agencies, and others, the Nurse Care Manager identifies and proactively manages the needs of patients with high risk or complex medical, behavioral health and/or psychosocial problems through office visits and telephonic support.

The Nurse Care Manager works with patients to develop and implement care plans based on patient goals, preferences, and disease states to promote improved health outcomes and quality of life. This individual will work as part of a system-wide team comprised of nurses, community health workers, and case managers. The Nurse Care Manager connects patients with appropriate internal and resources and community resources, facilitates referrals to appropriate care services, and supports patient self-management, and communicates with other care team members to reduce barriers to improved health care outcomes. The Nurse Care Manager serves as an integral member of the care team, assesses patients for risk of adverse health outcomes and high utilization of acute care services, and monitors the impact of care management interventions.

Essential Functions:

Provides Care Management Services

• Identify patients at high risk of adverse health outcomes (e.g., death, disability, inpatient admission, SNF admission or ED visit) through case finding activities including physician referrals, hospital/ED utilization data, payor reports, claims, or encounter data review identifying high cost/high risk disease states or patients.
• Provide comprehensive transitional care management involving coordination of care and services following critical events, such as emergency department use, hospital inpatient admission and discharge or skilled nursing facility admission and discharge.
• Build a panel of patients with high risk or complex medical, behavioral health and/or psychosocial problems and conduct regular longitudinal goal-directed outreach in person and telephonically. Ensure patient understands program benefits, care manager's role, how to make best use of the program, and obtain consent to participate.
• Engage patients in trusting relationships enabling effective intervention and support.
• Utilize motivational interviewing to conduct assessment(s) of patient condition, needs, preferences, clinical and psychosocial/SDOH barriers to optimal health and identify care/case management intervention opportunities.
• Develop a person-centered care management plan based on the patient's goals, strengths, and barriers to promote improved health care outcomes and quality of life. Ensures care plan goals are clear, actionable, measurable, and time sensitive.
• Implement the patient- approved plan of care in collaboration with the care team and patient through practice, community, home-based, and telephonic support
• Provide culturally competent interventions based on patient assessment and identified cultural needs.
• Provide comprehensive care management including self-management support, health promotion, connection/referral to appropriate physical/mental health/substance abuse providers and community-based organization social supports to decrease barriers to attending appointments and following the plan of care.
• Utilize Self-Management Support interventions to promote self-advocacy. Monitor the patient's level of readiness to change relative to their health goals. Support patients to make daily health related decisions and move toward self-care and management.
• Identify educational needs and provide education/ information to patients/caregivers on disease process, medication, diet needs, exercise, etc. in support of care plan goals.
• Advocate for patients to assure access and timely service delivery across the continuum of care and community resources.
• Optimize insurance and other benefits to support patient access to needed services.
• Provide care coordination with primary/specialty medical care, acute and outpatient medical, mental health and substance abuse services, and other care managers involved in supporting the individual and address any outstanding gaps in care.
• Work with inpatient staff, providers, and inpatient care managers to facilitate effective transition support through timely communication of information necessary for patient care, discharge planning and supporting appropriate patient self-management.
• Provide crisis intervention planning addressing events such as exacerbation of conditions, adverse medication reactions, or other potential crisis situations to ensure interventions are planned, documented and to arrange for additional support services as needed.
• Collaborate with patients to review progress relative to achievement of targeted behaviors, goals and objectives and modify goals and care management interventions as appropriate to the needs/progress of the individual.
• Evaluate progress towards goals and discharge patient from care management when goals are met, progress is stalled, or patient ceases to respond to outreach attempts
• Builds relationships with external partners to facilitate care coordination activities
• Complete documentation necessary for service billing.

Participates effectively as a member of the interdisciplinary care team:

• Foster positive working relationships with patients, providers and others involved in the patient's care and establish shared understanding of the care manager role.
• Identifies social determinants of health that impact patient health status and adherence to plan of care and makes appropriate referrals to other care team members
• Work effectively with others to coordinate patient access to care support services.
• Initiate and facilitate interdisciplinary care team meetings to share concerns/identify barriers and collaborate with patients and providers in developing strategies to support goal attainment.
• Document in Athena to ensure aligned view among all providers, care management activities, and patient progress on care plan goals and barriers.

Interactions with Program Team:

• Provide care plan and clinical guidance regarding mutual patients to team of community health workers and case managers
• Participate in case review meetings to share cases, discoveries, concerns and collaborate in problem-solving and shared learning.
• Attend team meetings, trainings, learning events, and other functions, as required.
• Share updated information related to appropriate community resources.
• Provide open communication to the entire team facilitating engagement and teamwork.
• Assist in defining standards of excellence for patient care planning.

Other Functions and Responsibilities

• Identify opportunities to improve program, processes, and services, highlighting obstacles to meeting patient needs.
• In collaboration with manager, develop tools to enhance care/case management program.
• Participate in measurement of care/case management program effectiveness.
• Handle confidential information in accordance with HIPAA, state and federal privacy and confidentiality rules.
• Perform other duties as assigned.

Supervisory Functions:

• None

Qualifications:

• Minimum Education: RN with Bachelor's degree in Nursing and current PA license.
• Minimum Experience: 2-3 years of clinical nursing experience. Experience in home health, community and public health nursing, federally qualified health centers, nursing case management, and/or care management preferred
• Professional or volunteer experience working with community-based organizations a plus
• Excellent communication skills and ability to form collaborative partnerships across all service settings.
• Good listening skills.
• Sound reasoning and problem-solving skills. Ability to assimilate new information and technologies into daily work.
• Strong computer skills: Competent in Microsoft Office products (Word, Excel, Outlook, PowerPoint). Strong EMR skills and experience working with multiple EMRs a plus
• Ability to interact with individuals with diverse cultural and religious customs.
• Experience working with patients from diverse cultural, racial, ethnic, religious, and linguistic backgrounds
• Experience utilizing phone, video, and in-person interpreters to provide patient care