Transitional Care Manager RN

SUMMARY OF JOB DUTIES

The Care Manager 3 is responsible for triaging, coordination, documentation, communication, and tracking of patient calls, cases, and records for a panel of critical and high acuity Traditional Medicare and Medicare Advantage Plan patients engaged in Complete Health Care Management programs and initiatives.

Care Management services are focused on critical or high risk, chronically ill, and post-acute patients, and include a combination of non-face-to-face and in person communication (electronic or phone) with patient (or HIPAA Rep) and clinical staff, physician, or other qualified health care professionals. However, the frequency and length of management is conducted as the patient's medical condition warrants. During the management period, a plan of care is established and implemented, and is reviewed and/or revised during each subsequent encounter.

A plan of care includes an electronic summary of the patient's physical, mental, cognitive, psychosocial, functional, environmental, and social assessments. It contains a record of all recommended preventive care services, medication reconciliation with review of adherence and potential interactions and oversight of patient self-management of medications, an inventory of clinicians, resources, and supports specific to the patient; including how the services of agencies and/or specialists unconnected to the designated physician's practice can be coordinated. It includes ensuring that ER and hospital clinical documents, consult notes and other records of care are current and available on the chart for review as needed.

The Care Manager 3 is responsible for ensuring that care and services are delivered appropriately and timely to his/her panel of patients. Under direction of and collaboration with the primary care provider and Value Based Care leadership, the Care Manager 3 identifies and delivers the appropriate level of care needed by each patient in his/her care. He/she oversees and ensures that each patient receives regular and thorough assessments, triage, medication reconciliation, ongoing goals of care assessments, and follow up as their ongoing condition and acuity status requires.

The Care Manager 3 coordinates efforts with the Quality Department to ensure that each patient is accurately assessed, and that Annual Wellness Visits are completed quality measures and gaps are closed. He/she accurately updates patient's problems list, diagnoses, health conditions, mediations list and Care Team and escalates concerns to the primary care provider.

ESSENTIAL JOB FUNCTIONS

• The Care Manager 3 follows and maintains a panel of critical and high acuity, chronically ill, or post-acute Care Management patients as assigned by leadership.

• Is responsible to coordinate and communicate with providers, staff, and patient's Care Team members (including specialists, Case Managers and patient's family and/or representative) regarding the patient's specific and appropriate acuity level of care needed, as determined by their chronic conditions, acute care events and social/living needs.

• Ensures that the care patients receive is efficient, thorough, timely and is properly documented to help patients avoid ER and urgent care visits, hospital admissions and readmissions. Assists in ensuring the best quality of life possible for each patient in their care.

• Works with the leadership to identify specific patient social and preventative care needs. Facilitates resolutions, when possible, with resources throughout an assigned geographic area.

• Provides regular reporting of activities and statistical status of the Care Management patients in his/her care to leadership as directed.

• The Care Manager 3 helps to fill in for other staff as needed.

• Participates in department rotating "on-call" schedule determined by leadership.

• Participates in pertinent meetings, workshops, seminars, and related forums as directed.

• Maintains confidentiality and follows HIPAA and OSHA guidelines.

• Maintains current Registered Nurse License in the state of employment.

• Ensures patient satisfaction by providing excellent service, putting Patients First

KNOWLEDGE/SKILLS/ABILITIES

The Care Manager 3 must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required.

• A general knowledge of primary care practice, clinics, knowledge of legal and ethical standards for the delivery of primary care and medical terminology is required.  

• Must demonstrate personal effectiveness and credibility, collaborative skills, communication proficiency and flexibility. Must demonstrate strong decision making and documentation skills.

• Possesses organizational and problem-solving skills: Identifies and resolves problems in a timely manner; gathers, analyzes, and communicates information skillfully; develops alternative solutions in an organized manner.

• Knows, understands, and works within the scope of his/her practice. Able to delegate responsibilities appropriately to staff licensure, education, and experience.

• Able to work independently and in a multidisciplinary team. Keeps leadership informed and seeks advise and/or help from management whenever needed.

• Able to manage difficult or emotional customer service situations and responds to requests for customer service and assistance in a timely and appropriate manner.

• Has excellent written and oral communication skills. Uses reason and speaks clearly, respectfully, and persuasively in positive and negative situations, focusing on resolving conflict.

• Shows respect and sensitivity for cultural diversity, promotes a harassment-free environment, and fosters a non-discriminatory climate.

• Keeps commitments; inspires the trust of others; works with integrity and ethically.

• Adapts to changes in the work environment; demonstrates willingness to change approaches or methods as needed to best fit the situation within practice guidelines.

MINIMUM REQUIREMENTS

• Current Licensed Registered Nurse (RN)

• 3 years of related care management, medical clinical experience and/or training is required; equivalent combination of education and experience considered as determined by leadership.

• To perform this job successfully, an individual must have knowledge of Word Processing and internet software.

• Athena EHR experience is Preferred.

WORKING ENVIRONMENT

The position requires sitting for long periods, climbing, stooping, kneeling, crouching, reaching, standing, lifting, grasping, feeling, talking, hearing, repetitive motions, and finger use. Pushing and pulling are occasionally required. Use of a computer, keyboard, and headset along with various office machines is an essential part of the job.

DISCLAIMER

The above statements are intended to describe the general nature and level of work being performed by the Care Manager 3. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. The Care Manager 3 may be required to perform duties outside of their normal responsibilities from time to time as needed or as directed by supervision.