CMRN (MNA) Ambulatory Nurse Case Manager Atrius Health

Transitional Care Coordinator

Explore opportunities with Atrius Health, part of the Optum family of businesses. We're an innovative health care leader and multi-specialty group practice, delivering an effective, connected system of care for adult and pediatric patients at 28 practice locations in eastern Massachusetts. Our entire team of providers (physicians, PA/NPs and ancillary clinicians) works collaboratively with a value-based philosophy within our group practice as well as with hospitals, rehab and nursing facilities. Be part of our vision to transform care and improve lives by building trust, understanding and shared decision-making with every patient. Join us and discover the meaning behind Caring. Connecting. Growing together.

Position in this function is responsible for providing on-site transitional care coordination to ensure safe transitions of care and optimal communication between treating facility, Patient/Family and Atrius Health. Responsible for coordinating patient transitions from Hospital to home or other care settings, ensuring a smooth discharge process and continuity of care

Position Details:

• Location: Beth Israel Deaconess Medical Center located at 330 Brookline Ave. Boston, MA 02215
• Department: Case Management
• Schedule: 40HRS Weekly M-F 8:00am- 4:30pm

Primary Responsibilities:

• Provides direct referral source servicing at identified facility, building and enriching relationships, identifying needs, problem solving and meeting or exceeding expectations of external customers
• Serves as an extension of the Atrius Health practice site, connecting with Atrius Health patients and/or families to bridge the Atrius Health practice to the patient
• Conducts review of the medical record for Atrius Health adult medical or surgical hospitalized patients
• Conducts initial assessment of patient within 24 - 48 hours (business days of admission)
• Subsequent review/progress note at least every 7 days or accompanying a change in condition/plan
• May provide educational and/or program material to the site facility staff in compliance with Atrius Health clinical initiatives, services and specialty programs
• Performs needs assessments of patients/families for services including but not limited to primary care, specialty care visits, skilled homecare, palliative care, hospice care (including hospice residence), and/or skilled nursing facility, to ensure appropriateness of services and expedite transitions of care
• Educates Atrius Health patients/families regarding provider relationships serviced through preferred homecare/SNF organizations
• Assesses adult medical/surgical Atrius Health patients for risk of readmission, and communicates identified risks with transition of care, outpatient case manager and/or primary care team
• Facilitates real-time review of contributing factors to readmission of patients and explores opportunities for acute care hospitalization (ACH) reduction
• Accesses Atrius Health patient's Epic medical record to determine current program enrollment for continuation of care
• Assesses patients admitted with Heart Failure (HF) or Chronic Obstructive Pulmonary Disease (COPD) for HTM/RPM and initiates referral to the appropriate program
• Initiates a referral to the Atrius health heart failure program when appropriate
• Collaborates with hospital-based case manager to facilitate advance care planning documents such as health care proxy or MOLST form
• Facilitates communication between patient's hospital-based care team and practice based primary care team when needed or requested
• Collaborates with transition of care team and hospital-based case manager to ensure post-hospital follow up visit is scheduled
• Provides supportive patient/family education for targeted diagnoses including heart failure, diabetes, COPD to ensure optimal preparation for home discharge
• Coordinates with the hospital-based case manager to facilitate regarding Atrius Health preferred provider networks
• Seeks opportunities to improve communication and collaboration amongst all clinical partners in patient care treating facility and internal/external partners or provider
• Collaborates and communicates with Manager and Atrius Health Case Manager to identify and address any issues or concerns
• Documentation: Maintains accurate records of the discharge planning process in the patient's medical record for legal, regulatory, and billing purposes
• Participates in service recovery as needed
• Promotes problem identification, resolution to barriers in care delivery, efficiency, productivity and customer satisfaction
• Builds relationships with physicians, referral sources, managed care and assigned facility(ies)
• Provides information, resource materials and education to all providers and case managers and solicits feedback
• Promotes Atrius Health specialty programs designed to meet the needs of patients, providers, and partners
• Assists with other referral source account coverage as needed
• Performs other duties as requested

Required Qualifications:

• Graduate of a State-approved school of nursing
• Current, unrestricted, license to practice professional nursing in the Commonwealth of Massachusetts
• American Heart Association Basic Life Support (BLS)
• Electronic medical record (EMR) experience and/or aptitude to master the EMR based on other technology experience
• Demonstrated proficiency using multiple software applications, including MS Office, EXCEL, Cloud based platforms and EPIC reporting workbench and dashboards
• Demonstrated solid critical thinking, problem solving, interpersonal and patient interviewing skills
• Demonstrated excellence in practice, documentation, and cost-effective care utilization Maintains high patient satisfaction
• Demonstrated ability to interpret clinical information, assess the implication of treatment and develop and implement a plan of care
• Demonstrated ability to interpret clinical information, apply UM criteria and health plan guidelines for decision making
• Demonstrated ability to work effectively in a faced paced team environment

Preferred Qualifications:

• Bachelor of Science in Nursing (BSN)
• Certification in Case Management (CCM) or CCM eligible
• 3+ years in utilization management or case management
• 3+ years clinical experience with home health care experience or strong knowledge base in home health and hospice care

Other Requirements:

• Able to use all electronic tools and applications relevant to the performance of the duties of the position, including but not limited to phone, keyboard, computer and computer applications
• Able to work in multiple locations and cover multiple primary care practices as needed
• Performs all job functions in compliance with applicable federal, state, local and company policies and procedures Accesses only the minimum necessary protected health information (PHI) for the performance of job duties Actively protects the confidentiality and privacy of all protected health information they access in all its forms (written, verbal, and electronic, etc) taking reasonable precautions to prohibit unauthorized access Complies with all Atrius Health and departmental privacy policies, procedures and protocols Follows HIPAA privacy guidelines without deviation when handling protected health information

Working Conditions / Physical Demands

• Busy clinical environment with frequent deadlines and interruptions
• May require some weekend or holiday coverage

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The hourly pay for this role will range from $40.21 to $74.74 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex,