Nurse Care Manager

About the role

The Nurse Care Manager will work with Suvida Healthcare's multidisciplinary care team to provide high quality care for our high-risk patients. They will collaborate with their multidisciplinary neighborhood center care team to develop organization-wide approaches to problem solving, tracking, and managing complex cases and populations.

Responsibilities

• Oversees chronic care and transitions of care management of high-risk patients within their care teams and neighborhood centers
• Serves as a resource to the multidisciplinary team for the management of complex patients, including chronic care management assessments and care plans
• Performs triage for patients via phone and addresses issues appropriately or forwards message to appropriate party for further interventions
• Responsible for ensuring efficient, organized patient transitions from acute and post-acute setting to home or other transitional care facility
• Performs comprehensive assessments for both physical, mental, and social risk factors that support individual patient needs while identifying and addressing barriers
• Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting
• Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated patients; monitors the patient’s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis: completion and reporting diagnostic testing, treatment plan and discharge plan; modification of plan of care, as necessary, to meet the ongoing needs of the patient; communicates relative information to the care team; assignment of appropriate levels of care; completion of all required documentation
• Covers and communicates with providers and all involved care team members in the discharge plan to ensure their participation and readiness
• Ensures that all elements critical to the plan of care, including discharge plans, have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care
• Knowledgeable of the Four Elements of the Coleman Model
• Coordinates and communicates with providers and all involved care team members in the discharge plan to ensure their participation and readiness
• Ensures that all elements critical to the plan of care, including discharge plans, have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care
• Collaborates/communicates with external case managers
• Initiates and facilitates referrals for home health care, hospice, medical equipment and supplies
• Actively participates in clinical performance improvement activities
• Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical, and patient satisfaction data
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency

Qualifications

• Minimum 2 years of experience as a Registered Nurse
• Minimum 2 years of experience in utilization management, case management, chronic care management, discharge planning, transitions of care management, cost/quality management program, and/or other related field
• Available to work during assigned clinic business hours
• Current working knowledge of chronic care management, discharge planning, utilization management, case management, performance improvement and/or managed care reimbursement
• Competency in chronic care management, pre-acute, and post-acute venues of care, and post-acute community resources
• Excellent interpersonal communication, leadership, collaboration, and negotiation skills
• Effective oral and written communication skills
• Strong technical skills including data analysis and management, competency in Microsoft Office suite, and Electronic Medical Records
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components
• Ability to work independently and exercise sound judgment in interactions with providers, payors, patients, and their families
• Experience with Medicare Advantage, Value-based care, and/or Managed Care desirable
• Bilingual/Bicultural (English and Spanish)