RN Continuum of Care Manager
3 weeks ago
As a RN Continuum of Care Manager at Prisma Health, you will play a vital role in managing targeted patient populations to achieve efficient and effective care delivery. You will coordinate, facilitate, monitor, and evaluate interventions to achieve desired outcomes, working as part of an interdisciplinary team to guide and track individuals across time and delivery sites.
Key Responsibilities- Facilitation of Patient-Centered Care
- Identify, evaluate, and enroll high-risk members of specified populations.
- Perform complete assessments of patients' current health status, including barriers to achieving optimal health, and available resources.
- Develop and implement initial Plans of Care and Self-Management Plans that highlight opportunities for improving clinical outcomes and/or utilization patterns.
- Facilitate and monitor the implementation of Plans of Care.
- Coordinate patient/family participation in Plans of Care and self-management.
- Utilize knowledge of community resources to facilitate achievement of goals.
- Coordinate patient education to achieve Plans of Care using evidence-based methods.
- Interdisciplinary Practice
- Participate in the development and execution of Plans of Care across the continuum of care, including acute, post-acute, and home settings.
- Demonstrate expertise in care management and serve as a resource to the interdisciplinary healthcare team.
- Integrate knowledge of external and internal regulatory requirements into the review and management of cases.
- Work collaboratively with inpatient and ambulatory Prisma Health staff, as well as non-Prisma Health staff as necessary to facilitate continuity of care.
- Serve as a bridge across the clinical setting and function as patients' consistent points of contact.
- Facilitate referrals to other disciplines and internal and community-based programs as appropriate to improve patient outcomes.
- Evidence-Based Care
- Utilize and incorporate knowledge of efficiency and effectiveness indicators when coordinating and facilitating Plans of Care.
- Increase knowledge of best practices and clinical standards of care and incorporate knowledge into practice.
- Measurements and Reporting
- Document in the medical record and on team tools, accurately reflecting collaborative care planning, interventions, and evaluation against defined targets and goals.
- Education
- Bachelor's degree in Nursing
- Experience
- 3 years total nursing experience with at least 1 year Care Management/Case Coordination experience
- Certifications/Registrations/Licenses
- South Carolina recognized R.N. License
- SOUTH CAROLINA DRIVERS LICENSE
- Other Requirements
- Proof of current auto liability coverage
- Must be willing to travel and have reliable personal transportation
- Obtain case management certification (CCM) within 2 years of hire or eligibility to sit for the certification exam
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