RN Care Manager, Post-Acute Liaison
hace 23 días
Windsor
Job Description SUMMARY OF RESPONSIBILITY: The RN Care Manager, Post-Acute Liaison is a professional Registered Nurse with broad clinical knowledge responsible for care management of high-risk patient populations with complex comorbidities. The RN will collaborate with the clinical care coordinator in the coordination of discharge plans as well as the coordination of post-acute stays and any home services. The individual will be responsible for building relationships with partnering post-acute care facilities and promoting evidence-based best practices in efficient methodologies to provide safe, quality care across the healthcare continuum. The RN Care Manager, Post-Acute Liaison is responsible for supporting the implementation of the SoNE Healthcare post-acute strategy which includes transitional care coordination of patients within post-acute care facilities. The Liaison is responsible for leading the collaboration of the post-acute care facilities patient care team to manage transitional ACO patients’ length of stay and readmission initiatives including but not limited to: • Patient attribution identification,, • Understanding the components of high value Skilled Nursing Facilities,, • Review of clinical documentation requisite to meet CMS requirements for Skill, and The Liaison is responsible for meeting routinely with the Skilled Nursing Facilities’ Utilization Review team related to decreasing length of stays and reducing readmission. The Liaison is also responsible for maintaining data tracking, reporting and analysis of key performance indicators and program metrics. The Liaison will also assist with other post-acute strategic initiatives, including protocol development, data tracking, and education of post-acute facilities, home care agencies, and other community partners as needed. ESSENTIAL FUNCTIONS: • Builds collegial working relationships with patient care teams, including patients and their families, to efficiently manage patient care across the healthcare continuum, • Manages the length of stay and discharge disposition reinforcing that the patient is at the right environment at the right time, consistent with Quadruple Aim, • Asks questions and influences decision point as needed to provide the patient with the most appropriate site of care for transition, • Maintains an accurate census of attributed patients and documents encounters utilizing EMR and non-EMR platforms, • Utilizes real-time data and Bamboo Health generated reports to track key performance indicators and identify areas of opportunity, • Collaborates with post-acute care facility to notify when ACO patient is admitted, confirming plan of care goals are established within 24 hours of admission, • Collaborates with home care agency to review discharge summary to verify that transitional gaps in care for the patient are addressed, • Collaborates with team members and other stakeholders to identify opportunities supporting patient transitions, • Participates in routine scorecard reviews with post-acute care facilities, • Seeks educational opportunities for professional development, • Provides a professional image of all aspects in interactions and functions., • Position may involve occasional travel to our high value post-acute care facilities QUALIFICATIONS AND COMPETENCIES: • Licensed Registered Nurse in CT and MA required, • CCM, ACMA, or other case management certification preferred, • Bachelor’s degree preferred, • Minimum 3 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, • 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 and build their self-management skills., • Knowledge of Medicare and/or Commercial insurance guidelines pertaining to patient care management in the ambulatory/community care setting is preferred., • Broad understanding of post-acute care, care management, Accountable Care Organizations and current trends in a value-based healthcare environment., • Strong collaboration and partnering skills to develop productive working partnerships with diverse teams., • 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 message and use of Motivational Interviewing to promote behavioral change., • Ability to communicate effectively with a 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 a remote setting with access to privacy is essential., • Bilingual candidates are encouraged to apply., • Strong coaching and development skills, • Maintains Protected Health Information with strict confidence and in a professional manner., • The ability to use computer software and Microsoft Office applications, including Excel spreadsheets, is required., • 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., • 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., • 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. 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 workday, 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, all employees must reside in New Hampshire, Rhode Island, Maine, Vermont, Connecticut, or Massachusetts., • For the safety and well-being of our employees, all employees are required to be fully vaccinated for influenza., • If you will be working in a remote or hybrid capacity, we require a stable internet connection. We recommend that you have an internet service provider with speeds of at least 30Mbps download/5Mbps upload. Adherence to SoNE Code of Conduct: • Code of Conduct: Employee will understand and follow the guidelines and standards outlined in the SoNE HEALTH Code of Conduct and demonstrate an understanding of the SoNE HEALTH Mission, Vision and Core Values., • Policies and Procedures: Employee will comply with all SoNE HEALTH policies and procedures relevant to their role, including those related to compliance, safety and confidentiality., • Regulatory Requirements: Employee will ensure actions and behaviors are in accordance with applicable laws, regulations, professional standards, policies, procedures and the Code of Conduct. SoNE HEALTH BENEFITS: We offer a competitive compensation package, which includes a comprehensive benefits program that begins on the first of the month following date of hire. Our benefits include: • Medical, dental, and vision insurance, • 401(k) retirement plan with employer match, • Short-Term Disability Insurance, • Long-Term Disability Insurance, • Basic Life & Accident Insurance, • Flexible Spending Accounts, • Voluntary Benefits, • Homeowners Insurance, • Auto Insurance, • Critical Illness Insurance, • Pet Discount Plans, • Earned time off, sick time, company holidays and one floating holiday, • Paid Volunteer Time, • Employee Assistance Program, • Educational Assistance (Tuition Reimbursement) after one year of employment, • Employee Discount Program for discounts on entertainment, travel, and shopping