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RN Care Manager

Company: SoNE HEALTH
Location: Hartford
Posted on: May 11, 2022

Job Description:

Job DescriptionSummary of Responsibility:The RN Care Management (RN CM) is an RN responsible for care management of high-risk patient populations with complex comorbidities. The RN CM maintains patient-centered care working with patients and their families/caregivers in collaboration with physicians and other health care team members. Standards of practice include care coordination, collaboration, accountability, advocacy, professionalism, and resource management. The RN CM practices comprehensive assessments along the care continuum, working with patients to meet physical, psychosocial, and/or spiritual needs. The RN CM uses motivational interviewing skills and knowledge to empower patients with care goal creation and meeting self-management action plans toward wellbeing.Essential Functions:

  • Knowledge of patient care delivered in the ambulatory setting, valuing the vision, mission, and strategies of Population Health in offering value-based care by improving patient care, enhancing patient experiences, reducing healthcare costs, and improving provider satisfaction for stakeholders.
  • Identify and engage appropriate patients for care management from lists and referrals, in collaboration with team leads
  • Ability to execute core care management duties:
    • Comprehensive assessment: bio-psycho-social-spiritual
    • Collaboration with patient and care team to develop patient-centered care plan, with particular focus on chronic disease management, social determinants, transitions of care and advanced care planning
    • Implementation of care plan; Working with clients, family and friend support networks and health care professionals to put care plans in place
    • Collaboration with community partners, such as VNA agencies, caregiver programs, DME providers and social service agencies;
      • Assessment of goal completion, with transition of patient to inactive or graduated status as appropriate.
      • Educate the patient on their medication conditions and medications, and build their self-management skills;
      • Use motivational interviewing to promote behavioral change;
      • Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.
        • Knowledge of common chronic/complex medical conditions presented in the population served with ability to:
        • Development and communication (with patient, caregiver and primary care physician/health care team) of a comprehensive care plan and patient action plan/goals of care based on evidence-based best practice for complex illness.
        • Pro-active management and follow-up according to care plan that includes incorporation of self-care and shared decision making in all aspects of patient care.
        • Coordination of skilled care with home care nurse, communicating home care notifications and authorizations to the health plan.
        • Coaching patients in the development of self-management goal setting and behavior change skills for attaining their goals.
        • Management and coordination of all transitions in care for complex patient panel:
        • Communicates care plan to all providers in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care and specialist).
        • Ensures that relevant providers receive timely clinical data for care treatment decisions in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care and specialty care).
          • Directs caregiver support, including ad hoc telephone advice.
          • Facilitation of patient and caregiver access to community resources relevant to patient's needs, including referrals to transportation programs, Meals on Wheels, senior centers, chore services, etc.
          • Identifies gaps in care and assists with performance improvement opportunities to close such gaps.
          • Attends required meetings and participates in committees as requested and assists with special projects as needed.
          • Cultivates positive relationships with all stakeholders, and members of the care team.
          • Educates patient, family and other health care members on the role and purpose of Care Coordination, its processes, disease/case management programs and outcomes and makes referral to appropriate Care Coordination services as needed.
          • Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health's Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior. Other Functions:
            • Performs other duties as assigned.The duties listed above are intended only as illustrative of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar or a logical assignment to the position.QUALIFICATIONS AND COMPETENCIES:
              • RN license required; RN licensure in CT and MA preferred; CCM, ACMA, or other case management certification preferred
              • Bachelor's Degree in nursing preferred
              • Three or more years of nursing experience, preferably with at least one year in care management, care coordination, or nurse navigation role; or alternatively, in an ambulatory care setting including telephonic triage
              • Knowledge of Medicare and/or Commercial insurance guidelines pertaining to patient care management in the ambulatory/community care setting is preferred.
              • Excellent organizational skills required, with the ability to communicate and work collaboratively with all levels of staff, payors, providers and office staff, and effectively utilizing all resources available.
              • Must be adaptable to unpredictable situations in a patient care setting while effectively managing assigned duties with precise attention-to-detail, accuracy and follow through, with minimal supervision.
              • Maintains Protected Health Information with strict confidence and in a professional manner.
              • Ability to use computer software and Microsoft Office applications, including Excel spreadsheets, is required.
              • Understanding of nationally recognized standards of care, managed care methodologies, and an awareness of dynamics occurring within the healthcare delivery system are key components of this position.
              • Ability to perform job with integrity and values consistent with the organization's Mission, Core Values and Standards.
              • May be required to work embedded within provider practice as patient needs and volume dictate.
              • Ability to travel to provider practices, hospitals, skilled nursing facilities, patients' homes, and other sites where patients receive care as need arises
              • Knowledge of defined area of nursing and allied health services. Familiarity with state-of-the-art developments in medical field.
                • Knowledge of federal and state laws relating to nursing/clinical care, professional ethics related to the delivery of nursing/clinical care.
                • Knowledge of risk assessment, health status indicators, multicultural factors, and community health issues.
                • Skill in collaborating with colleagues, providers, and patients to assess health needs of specific populations, developing strategies and specific programs to address these issues, and making presentations.
                • Must possess excellent interpersonal skills, with a flexible and creative approach to problem solving. Ability to facilitate discussion and build consensus.
                • Compassionate and able to relate to different clients with various needs
                • Strong management, organizational, communication, and analytical skills required.
                • Excellent verbal and written communication, with ability to practice active listening, conveying clear, concise messages. Ability to communicate effectively with variety of internal and external stakeholders.
                • Maintains current evidence-based practice knowledge within related field
                • Demonstrated ability of working effectively as a nurse of an interdisciplinary team, displaying safe clinical judgment and decision-making skills.
                • An ability to work independently in remote setting with access to privacy is essential.
                • Familiarity with Accountable Care and the Patient Centered Medical Home Model a plus
                • Bilingual candidates encouraged to apply.PHYSICAL AND MENTAL REQUIREMENTS:The Physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
                  • Ability to work long hours – over eight in a work day, and over 40 in a work week as necessary;
                  • Regularly required to use hands to finger, handle or feel objects, tools, or controls; reach with hands and arms; and talk or hear.
                  • Frequently is required to walk and sit.
                  • Occasionally required to stand; climb or balance; and stoop, kneel, crouch or crawl.
                  • Ability to lift and/or move up to 20 pounds.
                  • Vision abilities required by this job include close vision, color vision, peripheral vision, depth perception and ability to adjust focus.
                  • The dexterity necessary to utilize a computer keyboard on a regular basis is essential.ADDITIONAL REQUIREMENTS:As a condition of employment at SoNE HEALTH and for the safety and well-being of our employees, all employees are required to be fully vaccinated for influenza and COVID-19. Salary Range: $80,747 - $104,972

Keywords: SoNE HEALTH, Hartford , RN Care Manager, Executive , Hartford, Connecticut

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