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Who We AreAt 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?What Makes Us UniqueWe 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. How We WorkOur Culture & Core BeliefsEarn TrustBuilding RelationshipsCreating JoyDoing RightImproving Every DayMoving ForwardWhat You'll Do Position SummaryThe 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. ResponsibilitiesOversees chronic care and transitions of care management of high-risk patients within their care teams and neighborhood centersServes as a resource to the multidisciplinary team for the management of complex patients, including chronic care management assessments and care plansPerforms triage for patients via phone and addresses issues appropriately or forwards message to appropriate party for further interventionsResponsible for ensuring efficient, organized patient transitions from acute and post-acute setting to home or other transitional care facilityPerform comprehensive assessments for both physical, mental, and social risk factors that support individual patient needs while identifying and addressing barriersCoordinates/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 readinessCommunicates with and the patient and family regarding the discharge planning process to minimize any anxiety or apprehension and optimize patient outcomes and patient satisfactionKnowledgeable of the Four Elements of the Coleman ModelCoordinates post-discharge needs with providers, such as Durable Medical Equipment, Home Health needs, medications, and other suppliesSchedules patient for follow up with PCP or specialist within 7 days of dischargeReconciles discharge medication and works with PCP and clinical pharmacist for review post-dischargeReviews and evaluates patient to ensure that the patient meets criteria for home health admission or admission to other transitional care institutionsCoordinates discharge needs with patients, caregivers, and acute facility providers and ensures the arrangements with post-acute care providers and care team members are completedTracks and monitors readmissions to acute care facilities and assists with re-hospitalization reduction initiativesWorks with clinical team to establish care programs to help prevent readmissions and hospitalizations.Collaborates with the multidisciplinary care team to ensure awareness of discharges needing specific care and coordinationObtains patient medical records from acute care facilities, including orders, referrals, care team documentation, diagnostic testing results, and acute care visit summariesUtilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated patients; monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis: completion and reporting diagnostic testing, treatment plan and discharge plan; modification of plan of care, as necessary, to meet the ongoing needs of the patient; communicates relative information to the care team; assignment of appropriate levels of care; completion of all required documentationCollaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.Identifies at-risk populations using approved screening tool and follows established reporting procedures.Refers cases and issues to clinical leadership team and follows up as indicated.Ensures that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of careCommunicate with patients and caregivers to assess needs and develop an individualized continuing care plan in collaboration with providers.Collaborates and communicates with multidisciplinary care team and with transitions of care team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluationRefers appropriate cases for social work intervention as neededCollaborates/communicates with external case managers. Initiates and facilitates referrals for home health care, hospice, medical equipment and supplies.Actively participates in clinical performance improvement activitiesUses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical, and patient satisfaction dataCollects, analyzes, and addresses variances from the plan of care with multidisciplinary care teamDocuments assessments, phone calls, and patient interactions in the Electronic Medical Record in a timely mannerPromotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competencyOther duties as assignedWhat You'll BringKnowledge, Skills, and AbilitiesMinimum 2 years of experience as a Registered NurseMinimum 2 years of experience in utilization management, case management, chronic care management, discharge planning, transitions of care management, cost/quality management program, and/or other related fieldAvailable to work during assigned clinic business hoursCurrent working knowledge of chronic care management, discharge planning, utilization management, case management, performance improvement and/or managed care reimbursement Competency in chronic care management, pre-acute, and post-acute venues of care, and post-acute community resourcesExcellent interpersonal communication, leadership, collaboration, and negotiation skills Effective oral and written communication skillsStrong technical skills including data analysis and management, competency in Microsoft Office suite, and Electronic Medical RecordsStrong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components Ability to work independently and exercise sound judgment in interactions with providers, payors, patients, and their familiesAbility to travel for orientation and as needed (10% or less)Experience with Medicare Advantage, Value-based care, and/or Managed Care desirableBilingual/Bicultural (English and Spanish) PreferredEducation, Experience, Licensure, or Certification RequirementsBachelor's Degree in Nursing or healthcare related fieldMaster's PreferredActive Arizona or Multi-state Compact Registered Nurse License*This position is eligible for an $8,000 sign on bonus.Suvida Healthcare provides equal employment opportunities to all Team Members and applicants for employment and prohibits discrimination and harassment of any type with regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.
