Care Manager - Registered Nurse

Care Manager (CM) RN

The Care Manager (CM) RN will lead a multidisciplinary healthcare team in a primary care / telephonic setting, focusing on coaching and coordination of care for patients needing navigation, addressing nursing care needs and follow up after clinical events. The CM RN will identify the needs of patients at risk and assist the providers to develop processes for managing the patient's preventative care, transitions of care, and or chronic disease management using defined protocols as well as their own sound clinical judgement. This person will promote patient-centered care, working with primary care providers and medical home team members. The CM RN is a key role in the care coordination of patients attributed to value based contracts.

Duties and Responsibilities (including but not limited to):

• Evaluates patients for care management services, determines appropriate level of care coordination management for the patient
• Complete a comprehensive assessment to identify patient risk and develop a care plan utilizing clinical expertise and judgement to evaluate needs for alternative services as needed
• Work collaboratively with physicians and in-house resources including pharmacists, registered dieticians, social workers and other disciplines to create a person-centered care plan with measurable SMART goals
• Monitor and update care plan to include progress towards achieving established goals and self-management activities
• Interact with patient, family and providers and multidisciplinary care team to assess the options of care including use of benefits ad community resources to update care plan. Utilize developed systems, processes, and initiatives to engage patients in relevant case management activities necessary to promote wellness and care at the right place and time.
• Work collaboratively with physicians and in-house resources including pharmacists, registered dieticians, social workers and other disciplines to support patient adherence to medical plan of care.
• Supervise and act as a resource for non-clinical staff [i.e. care coordinators, social workers].
• Verify that appropriate home care, hospice care, and other ancillary services (DME, infusion services etc.) are in place and are being delivered as directed by the care team
• Coordinate necessary referrals and authorizations within care management areas
• Facilitate the information flow between hospitals, long-term care, specialists and home health representatives and the care team
• Use available data and work with physician and office staff to help identify high risk, high need, and potentially high-cost patients
• Coordinate care and communicate with multiple providers, internal and external to the practice.
• Identify and utilize cultural and community resources and align with the patient's cultural preferences as much as possible
• Verify that members are screened for behavioral health concerns (depression / substance abuse) and are receiving appropriate screening and behavioral health interventions.
• Facilitate any necessary follow-up behavioral health needs with local behavioral health providers.
• Attend required training and collaboration sessions [i.e., learning sessions, care management meetings, and practice team meetings] as scheduled.
• Provide and facilitate open communication, regarding patient status, with physicians and office staff.
• Obtain records from other physicians/labs/diagnostic centers as requested by the physicians and as needed for care coordination efforts.
• Develop constructive relationships with internal population health team members, participating providers, and community resources.
• Other job-related duties as assigned

Qualifications or Education, Training and Experience

• Compact RN License – California and NY Licensure preferred in addition
• Bachelor's degree in nursing preferred; Associate degree in nursing is minimum requirement.
• 1-2 years' experience in acute inpatient, rehabilitation, sub-acute, skilled facility, home care, ambulatory care management, or managed health plan.
• Preferred: Certified Case Management (CCM) certification
• Preferred: Care/Case Management experience

Working knowledge of the following required:

• Principles of utilization management; care management principles; basic knowledge of health plan contracts and benefit eligibility requirements; Hospital structures, Managed Care and payment systems
• Timely and accurate documentation of day-to-day activities in designated technology platform
• Adaptable to new technologies and software
• Proficiency in EMR system(s), Outlook and data entry experience preferred
• Basic PC skills (MS Word/Outlook/PPT/Excel)

Examples of Competencies:

• Ability to use independent judgment and to manage and impart confidential information.
• Ability to analyze and solve problems; requires details, data and facts that must be analyzed and challenged prior to making decisions.
• Strong communication and interpersonal skills.
• Ability to clearly communicate medical information to professional practitioners and/or the public.
• Excellent organization, prioritization, follow up, analytical and time management skills with ability to handle multiple priorities and deadlines.
• Good interpersonal skills, sense of urgency, being proactive and ownership for one's work.
• Dependable, with strong work ethic and extremely high degree personal integrity.
• Ability to deal with multiple interruptions on a continual basis that must be met with a friendly exchange with others.
• Ability to develop and implement new approaches to improve processes, procedures, or the general work environment.
• Ability to review critical issues, effectively solve problems and create action plans.

Work Environment

• Requires in home visits with patients roughly 30% of the time
• Otherwise based in office

Benefits:

As a firm passionate about health care, we're deeply committed to the health and wellness of our own team members. We offer comprehensive, affordable insurance plans for our team and their families, and a host of other unique benefits, such as a yearly stipend for wellness-related activities and a paid parental leave program.