Continuing Care Manager

4 weeks ago

Lebanon, United States Alice Peck Day Health Systems Full time
  • POSITION STANDARDS
    • Master's degree in nursing required.
    • Licensed as a Registered Nurse in the State of New Hampshire.
    • BCLS certification required within 30 days of hire.
    • Board Certification in Case Management (CCM or CMC) preferred. If not certified, willingness to work toward CCM Certification in reasonable timeframe.
    • Five years' experience in a health care setting.
    • Previous Experience as a Case Manager required.
    • Excellent interpersonal skills required.
    • Ability to build and maintain positive working relationships.
    • Excellent written and verbal communication skills.
    • Computer skills required.
    • Capable of prioritizing and completing a high volume of requests quickly and efficiently in multiple diverse environments with strong attention to detail.
    • Ability to work effectively in a self-directed role and make clear decisions.
  • POSITION PHYSICAL REQUIREMENTS
    • Anything listed here requires a pre-employment physical by Employee Health to determine if the employee is capable of meeting the requirements.
      • Physical Activity:
      • Upper Extremity:
      • Push/Pull/Lift/Carry:
  • PART TWO: FUNCTIONAL RESPONSIBILITY
    • Position Objective
      • The Continuing Case Manager participates in the management of illness, striving to achieve measured clinical and psychosocial advancements across the patient's healthcare continuum.
    • Performance Expectation
      • Manages and coordinates interdisciplinary care of defined populations through the care continuum from a clinical, psychosocial and environmental perspective.
      • Identifies high-risk patients requiring on-going coordination of care; completes a comprehensive patient/support system assessment, participates with the multidisciplinary team in developing a comprehensive treatment plan that will span the continuum of clinical and psychosocial issues and plan of care. Provides continuing support and coordination for patient/support system with multiple complex system needs, and manages and negotiates continuing care services for enrollees in various health insurance plans.
      • Utilizes innovative strategies to advocate for patient needs and negotiates complex systems to remove barriers and limitations in accessing health care in all areas including clinical.
      • Monitors the patient's transition across and within care settings (e.g., home, clinic, skilled nursing facility, rehabilitation, hospital, etc.).
      • Shares assessment and clinical, psychosocial and environmental care plan data with patient/support system consent as the patient moves through different care settings.
      • Identifies gaps in the care continuum and works with the community and provider networks to expand access to needed clinical, psychosocial and environmental services.
      • Participates in the development of clinical disease management strategies and identifies the appropriate measures for the evaluation of outcomes.
      • Participates in the development, maintenance, and coordination of a multidisciplinary care delivery system specific to individual patient needs and promotes effective resource utilization.
      • Collects and evaluates clinical and financial data/outcomes, including, but not limited to, patient satisfaction, health and functional status, and resource utilization.
      • Performs other duties as required or assigned.

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