Registered Nurse Community Care Manager House Calls

Job Description:

Provides longitudinal care management services for identified patients. Utilizes clinical expertise to perform care management screening, assessment/evaluation, and develop and implement a patient-centered plan of care with shared goals and appropriate interventions. Provides extraordinary and value-based care management. Works collaboratively with patients, family caregivers, significant others, healthcare providers, payers, community-based providers, and other involved parties to provide effective, efficient, and patient-centered care management services.

Posting Specifics

• Benefits Eligible: Yes
• Shift Details: Full time (40 budgeted hours). Monday-Friday 8-4:30, no holidays, weekends, or call. Possibility to transition to 4-10’s after probation.
• Unit/Location: This will be in the Ogden region-the main office is at McKay Dee but the RN will see patient’s in their homes in the area.
• Preferred Qualifications: Experienced RN with a Bachelor’s degree and experience seeing patient’s in their home, preferred.

Job Essentials

Understands, practices, and promotes the philosophy and guiding principles of integrated care management. Develops relationships and collaborates with case/care management staff in episodic settings and across the continuum to promote process integration, seamless transitions from one case/care management program to another, continuity of care, and avoid duplicative care management services/process.

Patient Identification: Screens, identifies, and prioritizes patients appropriate for the program. Assigns patients with identified needs to a primary planner. An appropriate primary planner is assigned based on the individual's needs.

Assessment/Evaluation: Typically assigned as the primary planner for clinically complex patients. Meets with the patient in a timely manner and conducts an initial care management assessment/evaluation.

Care Planning: Develops a patient-centered plan of care, involving the patient/family, caregiver/significant others in the process. Problems and strengths are defined, and shared goals and desired outcomes are established.
Intervention: Collaborates, educates, communicates, and networks with healthcare providers across the continuum to ensure the patient's care planning needs are met.

Intervention: Advocates on behalf of the patient, communicating and collaborating with healthcare providers, payers, physicians, and community-based services, where appropriate, to establish an appropriate and integrated care plan for each patient.

Intervention: Provides patient/family caregiver self-management education, referrals, and support.

Intervention: Promotes mental health integration by collaboration with mental health/behavioral health providers.

Intervention: Facilitates transitions of care from one healthcare setting to another. Actively participates in system and regional process improvement initiatives to improve transitions of care.

Intervention: Identifies and assists patients/members with palliative care and end-of-life care planning needs.

Re-assessment/Re-evaluation: Evaluates the effectiveness of the patient's plan of care and outcomes and modifies the plan of care or specific interventions, as appropriate.

Leadership: Functions as the team leader, ensuring effective day-to-day operations and problem solving, for the Community Case Management team. Promptly escalates concerns to appropriate chain of command.

Leadership: Effectively and efficiently leads interdisciplinary care conferences, using collaborative practice models that promote interdisciplinary care planning and teamwork.

Completes timely and accurate documentation in the medical record using knowledge of documentation standards for the department to facilitate communication with team members. Documentation is done in compliance with all clinical guidelines and billing/reimbursement standards.

Organizes and prioritizes daily work by assessing new, current, and discharging patient needs in area(s) of responsibility.
Ensures that productivity standards and expectations are met.
 

Minimum Qualifications:

• Current RN license in state of practice.
• Current Driver's License in the state of practice.
• RNs hired or promoted into this role need to have or obtain their BSN within three years of hire or promotion.
• Basic Life Support for Healthcare Providers.
• Three years of clinical nursing experience.
• Three years of experience working as a case/care manager in a healthcare setting.
• Record as a safe driver. Will be asked to provide a copy of their Motor V