Care Manager (RN) - Regional Hospital Float, System Staffing Office

About the role

Manages and coordinates interdisciplinary care of defined populations through the care continuum from wellness through end of life from a clinical, psychological, social and environmental perspective.

Responsibilities

• Identifies high risk patients requiring on-going coordination of care;
• Performs a comprehensive patient/family assessment, develops a comprehensive treatment plan to include clinical components that will span the continuum of psychosocial issues;
• Implements a plan of care to provide continuing support and coordination for patient/family with multiple complex system needs;
• Manages benefits and negotiates continuing care services for enrollees in various health insurance plans;
• Utilizes innovative strategies to advocate for patient needs and negotiates complex systems to remove barriers and limitations in accessing health care in all areas including clinical;
• Makes sure the patient’s transition across and within care settings (e.g., home, clinic, skilled nursing facility, rehabilitation, hospital, etc.) is smooth;
• Shares assessment and clinical, psychological, social and environmental care plan data with patient/family consent as the patient moves through different care settings;
• Identifies gaps in the care continuum and works with the community and provider networks to expand access to needed clinical, psychological, social and environmental services;
• Participates in the development of clinical disease management strategies and identifies the appropriate measures for the evaluation of outcomes;
• Participates in the development, maintenance, and coordination of an interdisciplinary care delivery system specific to individual patient needs and promotes effective resource utilization;
• Collects and evaluates clinical and financial data/outcomes, including, but not limited to, patient satisfaction, health and functional status, and resource utilization;
• Performs other duties as required or assigned.

Requirements

• Graduate from an accredited Nursing Program;
• Masters of Science Degree in Nursing (MSN) with 3 years of clinical experience;
• Licensed Registered Nurse with New Hampshire eligibility;
• Current BLS required.