Care Manager- RN

Northern Light Maine Coast Hospital

Department: Care Management

Position is located: Northern Light Maine Coast Hospital

Work Type: PRN

Hours Per Week: No Hours Assigned

Work Schedule: Variable

Summary :

This position is responsible for providing care management and discharge planning for the hospitals. Assesses, plans, implements and evaluates the needs of patients for discharge planning and care management. Assumes a leadership role with the interdisciplinary team to achieve optimal clinical and resource outcomes including supervision of care managers and swing coordinators at both/or MCMH/BHMH. Liaison with referring hospitals to consider transfers. Manage utilization and quality metrics. Coordinates care to minimize the fragmentation of health care delivery systems. This position is committed to the constant pursuit of excellence in improving the health status of the community.

Responsibilities :

• Collaborates with providers and practice staff in identifying appropriate patients for care management, utilizing established Care Management criteria.
• Performs initial and periodic holistic assessments for care managed population. This includes physical, psychological, and environmental as appropriate. The assessment includes a systematic and pertinent collection of data about the health status of the patient. Prioritize patients according to intensity, need and required follow up.
• Formulates and implements a care management plan in collaboration with Member Organizations that addresses the patient's identified needs by assessing the patient/family needs, issues, resources and care goals; determining the choices available to individual patients; educating the patient/family on the choices available.
• Establishes a care management plan that is mutually agreed upon by the health care team and the patient/family. Plans specific mutual self-management goals, objectives and interventions with the patients that are action-oriented and time specific.
• Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, issues and goals.
• Collaborates with the healthcare team to revise the care management plan when changes occur. Initiates care conferences to discuss multidisciplinary team responsibilities, patient progress, new problems, etc.
• Maintains knowledge of activity restrictions appropriate to the severity of injury or illness.
• Identifies and effectively utilizes community resources to meet the needs of patients/families. Facilitates patient access to community resources as appropriate.
• Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence. Interacts professionally with patient/family and involves patient/family in the formation of plan of care.
• Collaborates with providers, other healthcare team members to include inpatient facilities, the patient's payer and health system administrators to transitions of care and facilitate care across the healthcare continuum to optimize clinical and financial outcomes.
• Determines and completes appropriate referrals. Serves as a liaison to providers, patients and families for coordination of services.
• Maintains a working knowledge of payer requirements. Develops collaborative working relationships with insurance case managers; negotiates on behalf of patient with third parties for cost-effective, high quality services and to maximize the efficient use of resources.
• Maintains EMR databases on care managed population. Maintains accurate and timely documentation.
• Participates in regular team meetings and peer review activities. Participates in departmental and organizational committees, as applicable. Participates in the orientation of new personnel. Precepts and mentors peers. Promotes collaborative teamwork.
• Develops relationships across broad organizational lines and where innovative and unstructured situations arise. Relationships usually involve combined skills in communicating, understanding, developing and motivating people to the highest degree.
• Meets with the Directors individual and as a team and the care management teams on a regular basis to provide patient updates, identify issues and develop strategies for resolution.
• Performs all duties and responsibilities in accordance with the Nurse Practice Act and in accordance with basic principles and guidelines of professional nursing.
• Collaboratively works with ACO on data management and process improvements.
• Ensures documentation meets current standards and policies.
• Performs all other duties, as assigned by supervisor.

Other Information :

• BLS Required.

Competencies and Skills

• Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.
• Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of belonging, empowerment, and cooperation.
• Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.
• Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.

Credentials

• Required Registered Nurse

Education

• Required Associate's Degree

Working Conditions

• Potential exposure to abusive and/or aggressive people.
• Work with computers, typing, reading or writing.
• Potential exposure to diseases or infections.
• Need to drive to perform responsible duties.
• Potential exposure to hazardous materials.
• Lifting, moving and loading 20 to 30 pounds.
• Potential exposure to noise levels being uncomfortable.
• Prolonged periods of sitting.
• Potential exposure to noxious odors.
• Prolonged periods of standing.
• Potential exposure to very hot or cold temperatures.
• Prolonged periods of walking.

Coastal, Ellsworth, Maine, MCH, MCMH, Rural Health Care