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RN Care Manager
2 months ago
We are seeking a highly skilled RN Care Manager to join our team at Medix. As a key member of our healthcare organization, you will play a vital role in ensuring the seamless transition of patients from acute care settings to home or other transitional care facilities.
Key Responsibilities- Oversee chronic care and transitions of care management of high-risk patients within their care teams and neighborhood centers.
- Serve as a resource to the multidisciplinary team for the management of complex patients, including chronic care management assessments and care plans.
- Perform triage for patients via phone and address issues appropriately or forward messages to the appropriate party for further interventions.
- Ensure efficient, organized patient transitions from acute and post-acute settings to home or other transitional care facilities.
- Perform comprehensive assessments for both physical, mental, and social risk factors that support individual patient needs while identifying and addressing barriers.
- Coordinate/facilitate patient care progression throughout the continuum.
- Work collaboratively and maintain active communication with providers, nursing, and other members of the multidisciplinary care team to effect timely, appropriate patient management.
- Proactively identify/resolve issues impeding diagnostic, treatment progress, and discharge.
- Coordinate and communicate with providers and all involved care team members in the discharge plan to ensure their participation and readiness.
- Communicate with patients and families 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.
- Coordinate post-discharge needs with providers, such as Durable Medical Equipment, Home Health needs, medications, and other supplies.
- Schedule patients for follow-up with PCP or specialist within 7 days of discharge.
- Reconcile discharge medication and work with PCP and clinical pharmacist for review post-discharge.
- Review and evaluate patients to ensure that they meet criteria for home health admission or admission to other transitional care institutions.
- Coordinate discharge needs with patients, caregivers, and acute facility providers and ensure the arrangements with post-acute care providers and care team members are completed.
- Track and monitor readmissions to acute care facilities and assist with re-hospitalization reduction initiatives.
- Work with clinical teams to establish care programs to help prevent readmissions and hospitalizations.
- Collaborate with the multidisciplinary care team to ensure awareness of discharges needing specific care and coordination.
- Obtain patient medical records from acute care facilities, including orders, referrals, care team documentation, diagnostic testing results, and acute care visit summaries.
- Utilize advanced conflict resolution skills as necessary to ensure timely resolution of issues.
- Collaborate with the physician and all members of the multidisciplinary team to facilitate care for designated patients; monitor 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; facilitate 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; communicate relative information to the care team; assignment of appropriate levels of care; completion of all required documentation.
- Collaborate with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
- Identify at-risk populations using approved screening tools and follow established reporting procedures.
- Refer cases and issues to clinical leadership teams and follow up as indicated.
- Ensure 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 care.
- Communicate with patients and caregivers to assess needs and develop an individualized continuing care plan in collaboration with providers.
- Collaborate and communicate with multidisciplinary care teams and with transitions of care teams in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching, and ongoing evaluation.
- Refer appropriate cases for social work intervention as needed.
- Collaborate/communicate with external case managers. Initiate and facilitate referrals for home health care, hospice, medical equipment, and supplies.
- Actively participate in clinical performance improvement activities.
- Use data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical, and patient satisfaction data.
- Collect, analyze, and address variances from the plan of care with multidisciplinary care teams.
- Document assessments, phone calls, and patient interactions in the Electronic Medical Record in a timely manner.
- Promote individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency.
- Other duties as assigned.
- Bachelor's Degree in Nursing or healthcare-related field.
- Active Arizona or Multi-state Compact Registered Nurse License.
- 2 years of RN experience.
- 2 years of case management experience.
- Bilingual in Spanish and English.
- 401(k) plan.
- Dental insurance.
- Health insurance.
- Life insurance.
- Sick Time/Paid Time Off.
- Vision insurance.
This position is an on-site role.
