Intensive Community Manager, Complex Care (RN)

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 Nurse Case Manager 1 (RN) is responsible for achieving positive patient outcomes and managing quality of care across the continuum of care. The incumbent in this role will first and foremost serve as an advocate for our patients. He/She works closely with other members of the care team to develop effective plans of care and high levels of care coordination. This care planning and coordination may follow the patient from our centers into acute and post-acute facilities, as well as, their home environments. The Nurse Case Manager 1 (RN) role also involves establishing relationships with patients’ families and care givers, primary care physicians, specialists, other care providers, social workers, other case managers and nurses, acute and post-acute facilities, home health care companies, and health plans. He/She adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance and policies and procedures.

CORE JOB DUTIES/RESPONSIBILITIES:

• Manages and plans for transitions of care, discharge and post discharge follow-up for patients admitted to key, high-volume/high-priority hospitals.
• Establishes a trusting relationship with patients and their caregivers.
• Collaborates with clinical staff in the development and execution of the plan of care and achievement of goals. Reports variations to PCP/Transitional Care Physicians (TCP) and implements actions as appropriate.
• Builds relationships with preferred acute care providers (hospitalists, specialists, etc.).
• Directs referrals to preferred providers.
• Coordinates the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting. Coordinates the patient care, discharge and home planning processes with hospital case management departments, and other healthcare facilities.
• In conjunction with the PCP, Hospitalist, Medical Director, insurance case manager and the hospital case manager, coordinates the patient transition to the appropriate/least constrictive level of care using a preferred provider.
• Keeps the PCP aware of patient(s) condition via e-mail, DASH, HITS or other appropriate means of communication.
• Introduces self to patient/family and explains Nurse Case Manager’s role and processes to contact the Nurse Case Manager for questions, guidance and education.
• Provides high intensity engagement with patient and family.
• Facilitates patient/family conferences to review treatment goals and optimize resource utilization; provides family education and identifies post-hospital needs.
• Serves as a patient advocate. Enhances a collaborative relationship to maximize the patient/family’s ability to make informed decisions.
• Addresses advanced care planning including treatment goals and advance directives.
• Refers cases to social worker (Hospital and ChenMed/JenCare/Dedicated) for complex psychosocial and economic needs.
• Refers cases where patient and/or family would benefit from counseling required to complete complex discharge plan to social worker.
• Reports observed or suspected child or adult abuse pursuant to mandated requirements.
• Obtains onsite and EMR access at priority facilities.
• Maintains clinical and progress notes for each patient receiving care and provides progress report to PCP and others as appropriate.
• Submits required documentation in a timely manner and in appropriate computer system.
• Participates in surveys, studies and special projects as assigned.
• Conducts concurrent medical record review using specific indicators and criteria as approved by medical staff. Acts as patient advocate: investigates and reports adverse occurrences, and performs staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery.
• Promotes effective and efficient utilization of clinical resources and mobilizes resources to assist in achieving desired clinical outcomes within specific timeframe.
• Conducts review for appropriate utilization of services from admission through discharge. Evaluates patient satisfaction and quality of care provided.
• Communicates with physicians at regular intervals throughout hospitalization and develops an effective working relationship. Assists physicians to maintain appropriate cost, case and desired patient outcomes.
• Coordinates the provision of social services to patients, families and significant others to enable them to deal with the impact of illness on individual family functioning and to achieve maximum benefits from healthcare services.
• Completes expanded assessment of patients and family needs at time of admission. Completes psychosocial assessment.
• Directs and participates in the development and implementation of patient care policies and protocols to provide advice and guidance in handling unusual cases or patient needs.
• Attends meetings as assigned
• Performs other duties as assigned and modified at manager’s discretion.

There are 4 Nurse Case Manager 1 Roles with additional Essential Job Functions:

Acute Case Manager (primarily hospital based)

Responsibilities include all the above “Core” duties/responsibilities plus the following:

• Identify appropriateness of inpatient vs. observation status.
• Identify and manage safety risk (complete a social assessment), identify functional status (ADLs and PT needs), discuss medications and self-management, identify and correct knowledge deficits.
• Implement the ACM Coaching program with the appropriate patient population.
• In markets as appropriate, when patient in SNF, in conjunction with the post-acute physician, coordinate the transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed.
• Facilitate discharge to appropriate level of care and preferred providers
• Communicate discharge to all stakeholders including PCP, Center Manager and Community Case Manager.
• Document the appropriate date that the patient is medically discharged and update as appropriate.
• Contact the center manager to arrange for a follow-up PCP appointment prior to discharge and whenever possible, communicate this information to the patient/caregiver.
• As appropriate, discuss patients’ eligibility for CCM or DM programs and identify patient interest in participation.
• Coordinate acute UR physician meetings.

Community Case Manager (primarily clinic and community based)

Responsibilities include all the above “Core” duties/responsibilities plus the following:

• Provides telephonic or outpatient visits to patients at high-risk for readmissions (as identified by CM Plan) to the ER or hospital, to patients with active care planning requirements, to disease management patients per the Disease Management Plan and to others as referred via transitional care team, acute case managers and Transitional Care team.
• Visits may include evening and weekend hours with the goal of preventing ER visits or hospital admissions.
• Performs clinical functions including disease-oriented assessment and monitoring, medication monitoring, health education and self-care instructions in the outpatient setting.

Coordinate the Plan of Care:

• Conducts/coordinates initial case management assessment of patients to determine outpatient needs.
• Ensures individual plan of care reflects patient needs and services available.
• Makes recommendations to the team.
• Completes individual plan of care with patients and team members.
• Communicates instructions and methodologies as appropriate to ensure that the plan is implemented correctly.
• Assesses the environment of care, e.g., safety and security.
• Assesses the caregiver capacity and willingness to provide care.
• Assesses patient and caregiver educational needs.
• Coordinates, reports, documents and follows-up on Super Huddles and HPP/IDT meetings.
• Helps patients navigate health care systems, connecting them with community resources; orchestrates multiple facets of health care delivery and assists with administrative and logistical tasks.
• Coordinates the delivery of services to effectively address patient needs.
• Facilitates and coaches patients in using natural supports and mainstream community resources to address supportive needs.
• Maintains ongoing communication with families, community providers and others as needed to promote the health and well-being of patients.
• Establishes a supportive and motivational relationship with patients that support patient self-management
• Monitors the quality, frequency and appropriateness of HHA visits and other outpatient services.
• Assists patient and family with access to community/financial res