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Nurse Care Manager
4 months ago
**Who We Are**
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At Suvida Healthcare, we are not just caregivers; we're compassionate advocates dedicated to enriching the lives of our cherished seniors. As a Team Member with us, you will embark on a fulfilling journey where your skills and empathy converge to make a meaningful impact on the well-being of an underserved community and their families. Our multi-disciplinary primary care program is built to address the physical, behavioral, social, and cultural needs of Medicare-eligible Hispanic seniors.
Celebrate diversity and inclusivity in a workplace that attracts, engages, values, rewards, and recognizes the unique needs and backgrounds of both, our patients and our team. We believe that a rich tapestry of experiences, shared interests, and perspectives enhances the care we provide, making us a stronger, service-centered, and more compassionate healthcare family and Employer of Choice Will you join us _Suvidanos_, to help achieve our Higher Purpose?
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**What Makes Us Unique**
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We are an empowered primary care, clinical operations, and support team creating health equity through an exceptional clinical and consumer experience that improves the quality of life for the people, families, and neighborhoods we serve. We tailor our primary care program to the culture, language, social, and overall well-being of the seniors we serve.
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**How We Work**
- Our Culture & Core Beliefs_
- Earn Trust
- Building Relationships
- Creating Joy
- Doing Right
- Improving Every Day
- Moving Forward
**What You’ll Do**
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**Position Summary**
The Nurse Care Manager will work with Suvida Healthcare’s multidisciplinary care team in our Tucson West Location to provide high quality care for our high-risk patients. They will collaborate with their multidisciplinary neighborhood center care team to develop organization-wide approaches to problem solving, tracking, and managing complex cases and populations. This nurse will need to plan effectively in order to meet patient needs, identify social determinants of health, manage chronic conditions, and promote efficient utilization of resources.
The Nurse Care Manager will implement Suvida’s care pathways for patients with chronic conditions. They will also oversee transitions of care for patients to ensure safe transitions from acute to post-acute care, by coordinating timely and cost-effective care. The Nurse Care Manager will oversee highly complex and resource intense patients within their assigned care team.
They will collaborate with all providers, care team, patients, caregivers, payers, community resources, and external providers to promote quality of care.
**Responsibilities**- Oversees chronic care and transitions of care management of high-risk patients within their care teams and neighborhood centers- Serves as a resource to the multidisciplinary team for the management of complex patients, including chronic care management assessments and care plans- Performs triage for patients via phone and addresses issues appropriately or forwards message to appropriate party for further interventions- Responsible for ensuring efficient, organized patient transitions from acute and post-acute setting to home or other transitional care facility- Perform comprehensive assessments for both physical, mental, and social risk factors that support individual patient needs while identifying and addressing barriers- Coordinates/facilitates patient care progression throughout the continuum.- Works collaboratively and maintains active communication with providers, nursing, and other members of the multi-disciplinary care team to effect timely, appropriate patient management.- Proactively identifies/resolves issues impeding diagnostic, treatment progress, and discharge.- Coordinates and communicates with providers and all involved care team members in the discharge plan to ensure their participation and readiness- Communicates with and the patient and family regarding the discharge planning process to minimize any anxiety or apprehension and optimize patient outcomes and patient satisfaction- Knowledgeable of the Four Elements of the Coleman Model- Coordinates post-discharge needs with providers, such as Durable Medical Equipment, Home Health needs, medications, and other supplies- Schedules patient for follow up with PCP or specialist within 7 days of discharge- Reconciles discharge medication and works with PCP and clinical pharmacist for review post-discharge- Reviews and evaluates patient to ensure that the patient meets criteria for home health admission or admission to other transitional care institutions- Coordinates discharge needs with patients, caregivers, and acute facility providers and ensures the arrangements with post-acute care providers and care team members are completed- Tracks and monitors readmissions to acute care facilities and assists with re-hospitalization reduction initiatives- Works with clinical team to establish care programs to help pr
