Inpatient Discharge Care Manager (MNA) | Auburndale, Massachusetts | Atrius Health

Transitional Care CoordinatorExplore 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 carePosition Details:Location: Beth Israel Deaconess Medical Center located at 330 Brookline Ave. Boston, MA 02215Department: Case ManagementSchedule: 40HRS Weekly M-F 8:00am- 4:30pmPrimary Responsibilities:Provides direct referral source servicing at identified facility, building and enriching relationships, identifying needs, problem solving and meeting or exceeding expectations of external customersServes 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 patientConducts review of the medical record for Atrius Health adult medical or surgical hospitalized patientsConducts 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/planMay provide educational and/or program material to the site facility staff in compliance with Atrius Health clinical initiatives, services and specialty programsPerforms 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 careEducates Atrius Health patients/families regarding provider relationships serviced through preferred homecare/SNF organizationsAssesses 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 teamFacilitates real-time review of contributing factors to readmission of patients and explores opportunities for acute care hospitalization (ACH) reductionAccesses Atrius Health patient's Epic medical record to determine current program enrollment for continuation of careAssesses patients admitted with Heart Failure (HF) or Chronic Obstructive Pulmonary Disease (COPD) for HTM/RPM and initiates referral to the appropriate programInitiates a referral to the Atrius health heart failure program when appropriateCollaborates with hospital-based case manager to facilitate advance care planning documents such as health care proxy or MOLST formFacilitates communication between patient's hospital-based care team and practice based primary care team when needed or requestedCollaborates with transition of care team and hospital-based case manager to ensure post-hospital follow up visit is scheduledProvides supportive patient/family education for targeted diagnoses including heart failure, diabetes, COPD to ensure optimal preparation for home dischargeCoordinates with the hospital-based case manager to facilitate regarding Atrius Health preferred provider networksSeeks opportunities to improve communication and collaboration amongst all clinical partners in patient care treating facility and internal/external partners or providerCollaborates and communicates with Manager and Atrius Health Case Manager to identify and address any issues or concernsDocumentation: Maintains accurate records of the discharge planning process in the patient's medical record for legal, regulatory, and billing purposesParticipates in service recovery as neededPromotes problem identification, resolution to barriers in care delivery, efficiency, productivity and customer satisfactionBuilds 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 feedbackPromotes Atrius Health specialty programs designed to meet the needs of patients, providers, and partnersAssists with other referral source account coverage as neededPerforms other duties as requestedYou'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.Required Qualifications:Graduate of a State-approved school of nursingCurrent, unrestricted, license to practice professional nursing in the Commonwealth of MassachusettsAmerican Heart Association Basic Life Support (BLS)Electronic medical record (EMR) experience and/or aptitude to master the EMR based on other technology experienceDemonstrated proficiency using multiple software applications, including MS Office, EXCEL, Cloud based platforms and EPIC reporting workbench and dashboardsDemonstrated solid critical thinking, problem solving, interpersonal and patient interviewing skillsDemonstrated excellence in practice, documentation, and cost-effective care utilization Maintains high patient satisfactionDemonstrated ability to interpret clinical information, assess the implication of treatment and develop and implement a plan of careDemonstrated ability to interpret clinical information, apply UM criteria and health plan guidelines for decision makingDemonstrated ability to work effectively in a faced paced team environmentPreferred Qualifications:Bachelor of Science in Nursing (BSN)Certification in Case Management (CCM) or CCM eligible3+ years in utilization management or case management3+ years clinical experience with home health care experience or strong knowledge base in home health and hospice careOther 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 applicationsAble to work in multiple locations and cover multiple primary care practices as neededPerforms 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 informationWorking Conditions / Physical Demands:Busy clinical environment with frequent deadlines and interruptionsMay require some weekend or holiday coveragePay 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, sexual orientation, gender identity, disability, or protected veteran status