SUMMARY OF RESPONSIBILITY:

SoNE envisions integrated processes and transitions of care throughout the hospital and ambulatory settings that create fully aligned pre- and post- hospital components of care. The RN Care Manager Liaison- is a professional Registered Nurse with a broad clinical knowledge base. The RN Care Manager Liaison is responsible for leading the collaboration of the patient care team to manage MSSP ACO patients throughout their inpatient stay, ensuring the most appropriate discharge disposition and providing hand-off communication to the Transitional Care Management (TCM) RN who will follow the patient post-discharge for a period of 45 days.

Essential Functions:

• Within 24 working hours of the MSSP ACO patient admission, gather and document all necessary clinical information to determine best discharge plan for the patient
• Meet with patients (and/or families) while they are inpatient to provide education and support about the discharge process
• Assess the patient’s and family’s knowledge of medical, behavioral health and/or social conditions and provide education and self-management support based on the patient’s needs and preferences
• Build a collegial working relationship to efficiently manage the MSSP ACO patient across the health care continuum to manage LOS and discharge disposition reinforcing that the patient is in the right environment at the right time; ask questions and influence decision points as needed to provide the patient with the most appropriate site of care for transition
• In coordination with the hospital-based CM team, orchestrate in-person multidisciplinary rounds to gather and document all necessary clinical information form physical therapy, nursing, etc. to determine the best discharge plan for the patient.
• In collaboration with the Patient Care Team, identify all clinical and social concerns of the patient. Ensure documentation in appropriate systems
• Participate in hospital care team meetings as requested
• Educate patient and family on post-acute performance network if post-acute services are needed
• Maintain an accurate census of MSSP ACO patients and timely documentation of all interactions utilizing hospital electronic system
• Ensure next site of care provider has all needed clinical information to support a successful patient recovery
• Provides coverage for team members who have scheduled time off
• Perform other duties as assigned by the Executive Director of Population Health,

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

• Graduation from accredited School of nursing; BSN. Current Connecticut and Massachusetts RN license in good standing required. CCM certification preferred.
• Requires a minimum of 3-5 five years’ experience as a registered nurse with case management experience, hospital or community based.
• Knowledge of industry benchmarks as well as services provided in the post-acute health care setting.
• Professional communication skills needed for all clinical interactions as well as excellent interpersonal skills/techniques needed to promote patient, family and caregiver involvement.
• Approaches and responds to conflict in a constructive manner, with a focus on problem solving for a collaborative solution/resolution.
• Strong attention to detail. Track record of success in the coordination of care across multiple sites.
• Ability to simultaneously address and prioritize multiple projects, demands and issues.
• Possesses knowledge of quality improvement, TJC standards, state and federal regulations, six sigma and LEAN methodologies.
• Solid computer and analytical skills required.

WORKING CONDITIONS:

• Requires working in a hospital setting
• Must be able to travel to St. Francis Hospital on a daily basis, Monday-Friday
• Must be able to adapt to frequently changing work priorities.

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.

• 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.