Population Health RN Inpatient Case Manager - NBAX (Full Time, Day)

Job Description

Job Description

At Northbay Health, the Population Health RN Inpatient Case Manager (PHRNICM) is responsible for providing complex case management (CCM) to diverse groups of high-risk capitated populations. Complex case management is defined as the coordination of care and services for members who need help navigating the healthcare system to facilitate the appropriate delivery of the right care and services at the right place and time. These services are provided utilizing available resources across a continuum of care and in collaboration with members, caregivers, medical home providers, and ancillary health care providers. NBH utilizes a Population Health approach to identify diverse groups and to enhance member engagement and coordinate care delivery across populations to improve clinical outcomes. In addition to continuum of care responsibilities this position will assist within the inpatient case management department as needed.

Primary Job Duties

• Identify patients who are considered high risk for medical care resource utilization by reviewing information from referrals placed in the electronic health record (EHR). Referrals may also come through ED, Pharmacy, Hospital, and other departmental or systems reporting.
• Conducts assessments to identify the member’s needs and develops a specific care plan to address objectives, barriers, and goals identified during the assessment.
• Comprehensively identify strengths and opportunities for patients, including physical, behavioral and social support system capacities and degree of engagement with providers.
• Follow-up with patients and providers on identified health care needs and identify possible resources to address those concerns and/or work with care management team to address concerns in a multi-disciplinary method.
• Facilitate and manage referrals from referral specialist, providers, and other care management staff to ensure that identified red flags and healthcare needs of patients are addressed.
• Provide individual consults to patients on health education issues. Develop the health awareness of individuals, as well as groups and organizations, empowering them to make better health choices.
• Provide specialized oversight, implementation of care plans, and education to patients while exercising discretion and independent judgment; following established policies and procedures.
• Identifies “at risk” individuals and applies clinical based guidelines for development of a comprehensive plan of care. Obtains and evaluates relevant information (medical, psychosocial, financial) utilizing interviewing skills. Advocates for patients and their families throughout their episode of care. Maintains availability to patients/families as a resource to facilitate communication among providers and to monitor services rendered. When appropriate, meets directly with the patients and their families based on identified needs. Collaborates with patient, family, physicians and the interdisciplinary team to develop individualized comprehensive plans of care and to identify needed changes to the plan throughout care continuum. Remains involved until the patient achieves the planned level of functional health or closure criteria are met.
• As appropriate, coordinates/meets directly with the patient/family and the interdisciplinary team based on identified needs. Provides patient/family or significant other with information about appropriate providers.
• Involve the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process. Use proven processes to measure patient’s understanding and acceptance of the proposed plan(s), willingness to change, and support to maintain health behavior change. Apply teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness.
• Document and communicate with all provider(s) and member(s) of the care team as needed to minimize fragmented care. This will include navigating transitions of care, generally from hospital to home or community facilities.
• The PHRNICM will employ effective problem-solving techniques and conflict resolution skills to provide consistent quality care to the patient. Participates in department quality monitoring and improvement. Examples of this might include: department quality audits, developing and delivering training or other assigned projects.
• The PHRNICM will analyze and evaluate the effectiveness of Case Management on quality patient outcomes, fiscal parameters, customer satisfaction and system operations. Strategies for performance improvement will be accessed and communicated to UM Manager and Director of Care Management as appropriate.
• Manages the care of patients through health care systems based on the individual’s needs. Works in collaboration with physicians and appropriate health care providers for changes in plans as required. Advocates for the patient and family throughout the entire episode of care. Maintains availability to the patient/family as a resource to facilitate communication among providers and to monitor services rendered. Develops an individualized comprehensive plan of care in collaboration with the physicians, Social Services, and the interdisciplinary team. Tracks appropriate patient pathway through identification and assignment of DRG. Communicates with patient/family/physician/staff the anticipated discharge date (ADD). Proactive in communicating, assessing and reassessing patient throughout episode of care with development of alternative discharge plans as indicated. Works to transition patient to next appropriate level of care, appropriately involving Outpatient Case Management Services or other resources. Remains involved until the patient is discharged from the hospital and/or transfers case management function to outpatient services.
• Other duties as assigned to meet the needs of the population managed.