Care Manager - Care Transformation - FT - Day

Overview The Care Manager serves in an expanded nursing role to collaborate with patients and their health care team including Primary Care Providers, specialists, and hospitals to provide a model of care that ensures the delivery of quality, efficient and cost-effective healthcare services across the continuum. The Care Manager functions as a coordinator of patient care, assesses, plans, implements, monitors, and evaluates all options and services with the goal of optimizing the patient\'s health status. The Care Manager integrates evidence-based clinical guidelines, preventative guidelines, protocols, and other metrics in the development of transitions of care plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare for the targeted high-risk population. The Care Manager monitors patients across the health continuum with a focus on effective and safe transitions through the healthcare system with a goal to optimize resources and reduce avoidable readmissions back to acute care. The Care Manager manages performance feedback metrics to further refine the care model to maximize clinical, quality, and fiscal outcomes for the targeted population. The delivery of professional nursing care at Stormont-Vail HealthCare is guided by Jean Watson\'s Theory of Human Caring and the theory of Shared governance, both of which are congruent with the mission, vision, and values of the organization. Responsibilities Actively participates with clinic redesign and Patient Centered Medial Home (PCMH) expansion. Collaborates with primary care staff, social work staff, and other care team members to ensure optimal care coordination for the patient. Establish and maintain a supportive, collegial role with primary care practices engaged in improvement activity, particularly including assigned practices and their individual improvement team members. Initiates communication with patients upon learning they have been identified as high risk / targeted population. Pulls data from multiple systems and merge together to create a complete performance picture related to targeted populations. Implements interventions based on data and established guidelines. Monitors data for trends and individual outliers. Analyzes data for process improvement opportunities to impact patient outcomes. Optimizes patient care transitions by: Assuring an appropriate post-acute plan and utilization of services; Assisting the post-acute team in development of an appropriate discharge plan for post-acute discharge; Assures collaboration with primary care, social work & PCP care manager, other care team members, and community supports to ensure optimal care coordination for the patient. Guides patients through the health care system. Facilitates interaction and communication with health care staff providers. Provides disease/treatment specific education to both patients and families. Oversees scheduled appointments and patient testing and admissions. Reviews patient records. Documents medical information using the appropriate forms and/or electronic applications. Collects and tracks data related to targeted populations and implements interventions based on data and established guidelines. Participates in system wide/department patient care quality improvement activities as well as standards developments. Works closely with cross-functional teams to define analysis needs, identify trends and propose solutions. Appropriately delegates tasks and duties in the direction and coordination of health care team members, patient care, and department activities in accordance with the Kansas State Nurse Practice Act; demonstrates knowledge of KSNPA statutes and regulations. Education and Qualifications Bachelor\'s of Science in Nursing (BSN) Preferred Experience Qualifications 2 years Nursing experience in an acute or ambulatory setting. Required Case/care management experience. Preferred Skills and Abilities Demonstrates prudent professional and clinical judgement, effective problem solving skills, critical thinking, excellent organizational and interpersonal skills, creativity, flexibility, and the ability to multi-task. Demonstrates ability to be self-directed and purposeful in seeking the necessary knowledge and skills to enhance professionalism in order to provide high-quality care. Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment. Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals. Demonstrates ability to work autonomously and be directly accountable for practice. Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, priority setting, and work organization. Licenses and Certifications Registered Nurse - KSBN Required Driver\'s License - DMV Current Valid Driver’s License and Clean MVR with 3-year baseline and annual MVR review. Required Basic Life Support - BLS Required within 90 days of hire. What you will do Actively participates with clinic redesign and Patient Centered Medial Home (PCMH) expansion. Collaborates with primary care staff, social work staff, and other care team members to ensure optimal care coordination for the patient. Establish and maintain a supportive, collegial role with primary care practices engaged in improvement activity, particularly including assigned practices and their individual improvement team members. Initiates communication with patients upon learning they have been identified as high risk / targeted population. Pulls data from multiple systems and merge together to create a complete performance picture related to targeted populations. Implements interventions based on data and established guidelines. Monitors data for trends and individual outliers. Analyzes data for process improvement opportunities to impact patient outcomes. Optimizes patient care transitions by: Assuring an appropriate post-acute plan and utilization of services; Assisting the post-acute team in development of an appropriate discharge plan for post-acute discharge; Assures collaboration with primary care, social work & PCP care manager, other care team members, and community supports to ensure optimal care coordination for the patient. Guides patients through the health care system; Facilitates interaction and communication with health care staff providers; Provides disease/treatment specific education to both patients and families; Oversees scheduled appointment(s); Oversees patient testing and admissions; Reviews patient records; Documents medical information using the appropriate forms and/or electronic applications; Collects and tracks data related to targeted populations; Implements interventions based on data and established guidelines; Monitors data for trends and individual outliers; Analyzes data for process improvement opportunities to impact patient outcomes. Participates in system wide/department patient care quality improvement activities as well as standards developments. Works closely with the cross-functional teams to define analysis needs, identify trends and propose solutions. Appropriately delegates tasks and duties in the direction and coordination of health care team members, patient care, and department activities in accordance with the Kansas State Nurse Practice Act; demonstrates knowledge of KSNPA statutes and regulations. Travel Requirements 20% Driving between facilities. Working and Remote Requirements Required for All Jobs: Complies with all policies, standards, mandatory training and requirements of Stormont Vail Health; Performs other duties as assigned. Patient Facing Options: Position is Patient Facing. Remote Work Guidelines: Workspace is a quiet and distraction-free allowing the ability to comply with all security and privacy standards. Stable access to electricity and a minimum of 25mb upload and internet speed. Dedicate full attention to the job duties and communication with others during working hours. Adhere to break and attendance schedules agreed upon with supervisor. Abide by Stormont Vail\u2019s Remote Worker Policy and will review and acknowledge the Remote Work Agreement annually. Remote Work Capability Hybrid Scope No Supervisory Responsibility No Budget Responsibility Physical Demands Balancing: Occasionally 1-3 Hours Carrying: Occasionally 1-3 Hours Climbing (Ladders): Rarely less than 1 hour Climbing (Stairs): Rarely less than 1 hour Crawling: Rarely less than 1 hour Crouching: Rarely less than 1 hour Driving (Automatic): Occasionally 1-3 Hours Driving (Standard): Occasionally 1-3 Hours Eye/Hand/Foot Coordination: Occasionally 1-3 Hours Feeling: Occasionally 1-3 Hours Grasping (Fine Motor): Occasionally 1-3 Hours Grasping (Gross Hand): Occasionally 1-3 Hours Handling: Occasionally 1-3 Hours Hearing: Occasionally 1-3 Hours Kneeling: Occasionally 1-3 Hours Lifting: Occasionally 1-3 Hours up to 25 lbs Operate Foot Controls: Occasionally 1-3 Hours Pulling: Occasionally 1-3 Hours up to 25 lbs Pushing: Occasionally 1-3 Hours up to 25 lbs Reaching (Forward): Occasionally 1-3 Hours up to 25 lbs Reaching (Overhead): Occasionally 1-3 Hours up to 25 lbs Repetitive Motions: Occasionally 1-3 Hours Sitting: Occasionally 1-3 Hours Standing: Occasionally 1-3 Hours Stooping: Occasionally 1-3 Hours Talking: Occasionally 1-3 Hours Walking: Occasionally 1-3 Hours Working Conditions Infectious Diseases: Occasionally 1-3 Hours Other Atmospheric Conditions: Rarely less than 1 hour Hazards (other): Rarely less than 1 hour Equal Employment Opportunity Stormont Vail is an equal opportunity employer and adheres to the philosophy and practice of providing equal opportunities for all employees and prospective employees, without regard to race, color, ethnicity, sex, sexual orientation, gender identity and expression, religion, national origin, citizenship, age, marital status, uniformed service, disability or genetic information. This applies to all aspects of employment practices including hiring, firing, pay, benefits, promotions, lateral movements, job training, and any other terms or conditions of employment. Retaliation is prohibited against any person who files a claim of discrimination, participates in a discrimination investigation, or otherwise opposes an unlawful employment act based upon the above classifications. #J-18808-Ljbffr