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Community Care Nurse, Hospital and Community Care
3 months ago
**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 Manager, Community Clinical Care, HCT may directly manage a regional team that will include multiple areas, care management staff and data analyst support for the programs. As a member of the Hospital and Community Care Team, this role is responsible for high-value care across multiple regions, to serve as coach, mentor/trainer to all members of care management team, giving guidance in best practices, troubleshooting to optimize the value of care in hospital and community setting.
**ESSENTIAL JOB DUTIES/RESPONSIBILITIES**:
- Manages a team Community Care Nurses and Community Social Workers.
- Actively involved in the full employment cycle of direct reports, including but not limited to: participation in the recruitment process, annual performance appraisals, day-to-day oversight of staffing/scheduling needs, problem solving, exit interviews and termination/counseling decisions.
- Displays leadership skills, mentoring staff to achieve success.
- Provides structure and assures consistent execution of the Care Management Process (CMP), including Case Management (CM) and Disease Management (DM) plans. CMP is a collaborative model including patients, nurses, social workers, PCPs, specialists, other providers/practitioners and caregivers. Coordinates care with PCPs, Specialists and ancillary teams across the market.
- Advocates for and assists Community Care Nurses and Community Social Workers with ensuring patients achieve optimal health, access to care and appropriate utilization of resources.
- Consults with, encourages and influences physicians, specialists, and other providers to refer patients to care management for assessment, planning, implementation, coordination, monitoring and evaluation to develop an individualized care plan prior to hospitalization which can result in decreased admissions and hospital sick days. Aids in identifying areas of opportunities at the PCP, center, and market level.
- Serves as the resident CM and DM “expert” to support Community Care Nurse needs for market specific education.
- Facilitates medication reconciliation and adherence education; disease education and coaching; advance directive/end of life discussions and referral/authorization management with Community Care Nurse as needed.
- Educates and supports of Community Care Nurses at appropriate and repeated intervals, assesses and reassesses the patient’s progress utilizing telephone and other technologies and resources. Depending on the progress, urges appropriate interventions to obtain optimal outcome.
- Monitors and manages clinical and financial coordination of treatment plan of assigned patients to ensure timely, cost-effective, individualized service delivery.
- Assists with development and implementation of case management policies, processes, and standard operating procedures (SOPs) as appropriate.
- Precepts new Community Care Nurses.
- Assists with quality audits and data analyses to identify opportunities for improvement.
- Identifies problems or any dissatisfaction experienced by patients or referring source and works to resolve them to a high degree of service excellence.
- Formulates, implements and evaluates educational strategies for staff, providing best outcomes for our patients and family members.
- Identifies and shares best practices to advance efficiency and performance.
- Assists with workflow efficiency improvement for clinical and operational practices.
- Working with COE team for Community Social Workers for best practices
**_ Other responsibilities may include:_**
- Consistently demonstrates efficient use of time and resources within established budget parameters, while actively participating in identification and implementation of cost saving strategies.
- Some direct patient care as needed if/when Community Care Nurse is unavailable. Provides support for catastrophic cases within the clinical support group.
- Supports quality improvement initiatives.
- Serves as a resource for Community Social Worker.
- Anticipates provider and/or patient needs and respond appropriately.
- Performs other duties as assigned and modified at manager’s discretion.
**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.
- Ability to plan, implement and evaluate individual patient care plans.
- Ability to work as oversight
