RN Case manager

We’re unique.  You should be, too.

We’re changing lives every day.  For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts?  Do you inspire others with your kindness and joy?

We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

The Nurse Case Manager I position is responsible for achieving positive patient outcomes and manage quality of care across the continuum of care. The Nurse Case Manager I will first and foremost serve as an advocate for our patients. In this capacity, this person will work with other members of the care team to develop effective plans of care and high levels of care coordination. This care planning and coordination may follow the patient from our centers into acute and post-acute facilities, as well as their home environments. It will also involve key relationships with patients’ families and care givers, primary care physicians, specialists, other care providers, social workers, other case managers and nurses, acute and post-acute facilities, home health care companies, and health plans. The Nurse Case Manager I will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures.

Primary Duties and Responsibilities

• Manage and plan for transitions of care, discharge and post discharge follow up for patients admitted to key high volume/high priority hospitals.
• Collaborate with clinical staff in the development and execution of the plan of care and achievement of goals.  Report variations to PCP/ transitional care physicians (TCP) and implement actions as appropriate.
• Build relationships with preferred acute care providers (hospitalists, specialists).
• Direct referrals to preferred providers.
• Coordinate the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting. Coordinate the patient care, discharge, and home planning processes with hospital case management departments, and other healthcare facilities.
• In conjunction with the PCP, hospitalist, Medical Director of Transitional Care, insurance case manager and the hospital case manager, coordinate the patient transition to the appropriate/least constrictive level of care using a preferred provider.
• Keep the PCP aware of patient condition via e-mail, DASH, HITS or other appropriate means of communication.
• Introduce self to patient/family and explain Nurse Case Manager’s role and process to contact Nurse Case Manager’s for questions, guidance and education.
• Provide high intensity engagement with patient and family.
• Facilitate patient/family conferences to review treatment goals, optimize resource utilization, provide family education and identify post-hospital needs.
• Enhance a collaborative relationship to maximize the patient’s/family’s ability to make informed decisions. 
• Address advanced care planning including treatment goals and advance directives.
• Refers cases to social worker (hospital and ChenMed/JenCare) for complex psychosocial and economic needs.
• Refers cases where patients and/or family would benefit from counseling required to complete complex discharge plan to social worker.
• Obtain onsite and EMR access at priority facilities.
• Maintain clinical and progress notes for each patient receiving care and provide progress report to PCP and others as appropriate.
• Submit required documentation in a timely manner and in appropriate computer system.
• Participate in surveys, studies and special projects as assigned.
• Conduct concurrent medical record review using specific indicators and criteria as approved by medical staff.  Acts as patient advocate: investigates and reports adverse occurrences, and performs staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery.
• Promote effective and efficient utilization of clinical resources and mobilizes resources to assist in achieving desired clinical outcomes within specific timeframe.
• Conducts review for appropriate utilization of services from admission through discharge. Evaluate patient satisfaction and quality of care provided.
• Communicates with physicians at regular intervals throughout hospitalization and develops an effective working relationship. Assist physicians to maintain appropriate cost, case, and desired patient outcomes.
• Coordinates the provision of social services to patients, families, and significant others to enable them to deal with the impact of illness on individual family functioning and to achieve maximum benefits from healthcare services.
• Complete expanded assessment of patients and family needs at time of admission. Complete psychosocial assessment.
• Serve as a patient advocate. Enhances a collaborative relationship to maximize the patient’s and family’s ability to make informed decisions.
• Facilitates interdisciplinary patient care rounds and/or conferences to review treatment goals, optimize resource utilization, provide family education and identified post-hospital needs.
• Directs and participates in the development and implementation of patient care policies and protocols in order to provide advice and guidance in handling special cases or patient needs.
• Other duties as assigned and modified at manager’s discretion.
• There are 4 Nurse Case Manager I Roles With Additional Essential Job Functions:
• Acute Case Manager (primarily hospital based)
• Responsibilities include but are not limited to:
• Establish a trusting relationship with patients and their caregivers
• Coordinate the integration of social services/case management functions in the ER, acute and post-acute setting. 
• Coordinate the patient care, discharge, and home planning processes with patient/family, insurance case managers and hospital case management departments, and other healthcare facilities.
• In conjunction with the PCP, hospitalist, TCP, insurance case manager and the hospital    case manager, coordinate and communicate the timely patient transition to the most appropriate/least restrictive level of care using a preferred provider.
• Identify and manage safety risk (complete a social assessment), identify functional status (ADLs and PT needs), discuss medications and self-management, identify and correct knowledge deficits.
• Notify center of need for PCP 4 day post hospital discharge visit
• In markets as appropriate, when patient in SNF, in conjunction with the post-acute physician, coordinate the transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed.
• Identify appropriateness of inpatient vs. observation status. 
• Facilitate discharge to appropriate level of care and preferred providers.
• Document the appropriate date that the patient is medically discharged and update as appropriate.
• When possible, contact the center manager to arrange for a follow-up PCP appointment prior to discharge and communicate this information to the patient/caregiver.
• As appropriate, discuss patients’ eligibility for CCM or DM programs and identify patient interest in participation.
• Coordinate acute UR physician meetings. 
• Community Case Manager (primarily clinic and community based)
• Responsibilities Include but are not limited to:
• Provide telephonic or outpatient visits to patients at high risk for readmissions (as identified by CM Plan) to the ER or hospital, to patients with active care planning requirements, to disease management patients per the Disease Management Plan and to others as referred via transitional care team, acute case managers and HPP/IDT team.
• Visits may include evening and weekend hours with the goal of preventing ER visits or hospital admissions.
• Perform clinical functions including disease-oriented assessment and monitoring, medication monitoring, health education and self-care instructions in the outpatient setting.
• Coordinate the Plan of Care:
• Conduct/coordinate initial case management assessment of patients to determine outpatient needs.
• Ensure individual plan of care reflects patient needs and services available. 
• Make recommendations to the team. 
• Complete individual plan of care with patients and team members.
• Communicate instruction and methodologies as appropriate to ensure that the plan is implemented correctly.
• Assess the environment of care, e.g., safety and security.
• Assess the caregiver capacity and willingness to provide care.
• Assess patient and caregiver educational needs.
• Coordinate, document and follow-up on Super Huddles and HPP/IDT meetings.
• Report observed or suspected child or adult abuse pursuant to mandated requirements.
• Help patients navigate health care systems, connecting them with community resources, orchestrate multiple facets of health care delivery, and assist with administrative and logistical tasks.
• Coordinate the delivery of services to effectively address patient needs.
• Facilitate and coach patients in using natural supports and mainstream community resources to address supportive needs.
• Maintain ongoing communication with families, community providers and others as needed to promote the health and well-being of patients.
• Establish a supportive and motivational relationship with patients that support patient self-management
• Facilitate patient/family conferences to review treatment goals, optimize resource utilization, provide family education and identify home needs.
• Monitor the quality, frequency and appropriateness of HHA visits and other outpatient services.
• Assist patient and family with access to community/financial resources and refer cases to social worker as appropriate.
• Community/Skilled Nursing Facility Case Manager (Community Case Manager Role with additional SNF duties as assigned)
• Responsibilities include but are not limited to:
• Community Case Manager role as above.
• CM telephonic or onsite visits to SNFs, communication with PT, social workers, patient and families as appropriate.
• Validate appropriate level of care/LOS.
• Validate Discharge plan for safe transition home, utilization of preferred providers or timely transition to long term care.
• Remind patient of need for 4-day PCP post hospital/SNF discharge visit and future visits
• Collaborate with Humana Onsite SNF CMs.
• Transitional Case Manager (Blended Acute and Community Case Manager Roles)
• Responsibilities include but are not limited to:
• Acute and Community Case Manager roles as above.
• Onsite patient visitation, risk assessment, and care coordination in the acute and community settings.
• Discharge needs assessment and planning.
• Assist patient with engaging community resources.
• Post discharge telephone calls with medication reconciliation.
• Post discharge follow up appointment scheduling.
• Home visits with case management assessment including risk and needs assessments.
• Ongoing monitoring of high risk patients with select conditions (congestive heart failure, chronic obstructive pulmonary disease, etc.)
• Multidisciplinary case conferences.

• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
• Critical thinking skills required.
• Ability to work autonomously is required.
• Ability to monitor, assess and record patients’ progress and make adjustments accordingly.
• Ability to plan, implement and evaluate individual patient care plans.
• Knowledge of nursing and case management theory and practice.
• Knowledge of patient care charts and patient histories.
• Knowledge of clinical and social services documentation procedures and standards.
• Knowledge of community health services and social services support agencies and networks.
• Organizing and coordinating skills.
• Ability to communicate technical information to non-technical personnel.
• Fluent in English.
• This position requires minimal travel.
• Associate Degree highly desired.
• Bachelor Degree in Nursing or RN with Bachelor Degree in related field a plus.
• Must be a Registered Nurse with minimum two (2) years of clinical experience.  
• Minimum of one (1) years of utilization review and/or case management, home health, discharge planning experience.
• Certified Case Manager certification is preferred.
• Certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN) desired.