Complex Care Manager - Readmissions RN

Complex Care Manager - Readmissions RN

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Ideal candidate for this role will be a Registered Nurse.

A Complex Care Manager is accountable and responsible for coordinating or evaluating the cases for patients with multiple chronic conditions, high-risk health concerns, readmission, or denial of patient status. You will strive to achieve optimal clinical and quality outcomes by effectively managing care and resources to reduce unnecessary utilization. Your primary responsibility will be conducting electronic medical record (EMR) reviews and/or patient interviewsvia face-to-face or telephonic engagementto assess, identify, and close clinical and non-clinical gaps in patient care.

Essential Responsibilities

Responsibilities listed in this section are core to the position. Inability to perform these responsibilities with or without an accommodation may result in disqualification from the position.

• Conducts EMR reviews and/or patient interviews via face-to-face and/or telephonic engagements to assess, identify, and address clinical and non-clinical gaps in patient care.
• Performs readmission reviews to evaluate contributing factors and implement strategies to reduce avoidable hospitalizations.
• Manages denial cases, including reviewing medical necessity, collaborating with physicians and payers, and advocating for appropriate patient care coverage.
• Facilitates complex discharge planning, ensuring safe and effective transitions of care for patients requiring specialized placement or services.
• Assists with the collection, analysis, and benchmarking of utilization, process, and outcome metrics to identify trends and areas for improvement.
• Analyzes productivity measures and evaluates the effectiveness of care management strategies in achieving clinical, financial, and patient-centered outcomes.
• Researches, evaluates, and recommends resources to meet medical and non-medical needs of patients and families.
• Utilizes clinical expertise and understanding of care management, Medicare regulations, and contributes to the goals of cost containment and quality care and provides safe and appropriate transitions of care.
• Collaborates, refers, and communicates across all programs to ensure appropriate coordination of services.
• Works collaboratively and maintains active communication with physicians, nursing, and other members of the interdisciplinary team to effect timely and appropriate patient management.
• Serves as an advocate, placing the needs of patients and their families first. Delivering compassionate care that is whole person care: body, mind, and spirit.
• Supports shared decision making and encourages patient adherence to their care plans.
• Promote patient and family responsibility and self-management.
• Conducts EMR reviews and patient interviews via face-to-face and/or telephonic engagements to assess, identify, and close clinical and non-clinical gaps in patient care.
• Evaluate changes in patient-reported symptoms and conduct additional triage and screening to determine next steps.
• Assists with the collection, analysis and benchmarking of utilization, process, and outcomes metrics.
• Analyzes productivity. Measure outcomes and effectiveness of care management including clinical, financial, quality of life and patient/family satisfaction. Identifies opportunities for continuous improvement.
• Participates and promotes performance improvement projects.
• Supervise and mentor students
• Represent the care management department in hospital committees and task forces.

General Responsibilities

• Performs other duties as assigned.

Minimum Qualifications

Education Requirements

• Nurses: Bachelor of Science in Nursing (BSN) required.
• Social Workers: Graduate of an accredited school of social work. License Master Social Worker (LMSW) under supervision or Licensed Clinical Social Worker (LCSW) required.

Experience Requirements

• At least 5 years Care Management experience, 1 in an acute or ambulatory care setting.

License/Certification/Registration Requirements

• If applying as a Registered Nurse: Current Registered Nurse License (RN License issued by the Oklahoma State Board of Nursing, or a current multistate compact Registered Nurse (eNLC)).
• If applying as a Social Worker: Current Licensed Master Social Worker (LMSW) or under supervision for Licensed Clinical Social Work (LCSW) or LCSW from the Oklahoma State Board of Licensed Social Workers.
• Basic Life Support from the American Heart Association required.

Knowledge/Skills/Abilities Required

• Professional demeanor. Self-directed. Ability to work as a member of a team.
• Excellent verbal and written communication (including documentation) skills.
• Detailed - oriented with excellent organizational skills.
• Commitment to fostering a culture of continuous learning, quality improvement, and patient-centered care.
• Strong assessment, critical thinking, and problem-solving skills
• Strong knowledge of healthcare regulations, including CMS guideline
• Serve as liaison between patients, families, and healthcare providers.
• Excellent organizational and project management abilities.
• Knowledge and skill in chronic disease management
• Strong organizational and time-management
• Ability to assess, adapt, and calmly respond to changing and crisis environment.
• Ability to facilitate patient access to community resources.
• Proficiency in utilizing electronic health records (EHR) and care management software.