Care Manager - RN

About the role

The Care Manager works collaboratively with interdisciplinary and healthcare team members, both internal and external to the organization, to facilitate patient care through effective utilization and monitoring of healthcare resources. This role assumes a leadership role to achieve safe discharge planning along with desired clinical and financial outcomes.

Responsibilities

• Completes a face-to-face assessment of all new patients in caseload within 24 hours or next business day to identify appropriateness for acute care, level of care, and to anticipate high-level care planning needs.
• Screens high-risk patients with a lace score greater than or equal to 10 to reduce 30-day readmissions.
• Consults with attending physicians regarding potential care transition barriers identified as a result of this process.
• Assumes transition process in collaboration with the multidisciplinary team and patient/family and assists with executing the plans and interventions to facilitate the stay and manage the length of stay.
• Facilitates patient care conferences/complex case conferences proactively as needs are identified to reduce avoidable readmissions.
• Provides an Important Message notice and choice on Medicare patients as appropriate.
• Identifies and reports process improvement opportunities by capturing delays in care by documenting avoidable days in MIDAS per guidelines.
• Maintains contact with the patient, family, physician, and team members to ensure the most cost-effective plan of care is being carried out and appropriate in-network providers are being utilized.
• Establishes a caring relationship with patients and their caregivers, promotes patient engagement, and guides patients/families through the transition phase.
• Collaborates with social workers for patients with complex, clinical, financial, and psycho-social needs.
• Reviews physician orders and patient progression on a daily basis and intervenes with care coordination as needed.
• Collaborates with other departments to eliminate barriers, as necessary.
• Participates in multi-disciplinary rounds, long-stay rounds, and meetings that promote comprehensive and coordinated care plans and monitors progress against goals.
• Documents plan of care and updates /changes in plan of care in the electronic medical record.
• In collaboration with the appropriate services, arranges home care, DME, and infusion/post-acute services in partnership with the social worker.
• Maintains good working relationships with community providers.
• Serves in obtaining legal guardianship, competency determinations, adoption-related situations, and all cases where adult or child abuse is a concern.
• Makes sure all legal documents are completed.
• Collaborates with the Corporate Director and Manager of Case Management as needed.
• Provides counseling and support as needed.
• Identifies cases which would benefit from palliative care and elicits palliative consults as needed.

Qualifications

• RN with 2 years' experience required, BSN and/or related bachelor’s degree in a healthcare field preferred.
• Any relevant experience in utilization and/or case management.
• Knowledge of managed care, governmental payers, and third-party reimbursement.
• Skills in using Microsoft Office applications and Information systems including but not limited to MIDAS.
• Demonstrated critical thinking skills and ability to prioritize work load.
• Strong interpersonal skills relative to both professional and lay interactions.
• Strong organizational skills.
• Demonstrated working knowledge of performance improvement activities.
• Demonstrated working knowledge of data management/reporting practices.
• Strong communication skills.