Nurse Case Manager - ChenMed

We’re unique.  You should be, too.

We’re changing lives every day.  For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts?  Do you inspire others with your kindness and joy?

We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

• The Acute Care Nurse is responsible for achieving positive patient outcomes, managing quality of care across the continuum of care with efficient allocation of healthcare resources. This role will first and foremost serve as an advocate for our patients and families as they navigate through external providers and healthcare systems. The Acute Care Nurse is an important member of the Hospital & Community Care Teams and will use all available resources and leverage other members of the healthcare care team to develop effective plans of care and with focus on delivering high levels of longitudinal care coordination. The Acute Care Nurse role also involves establishing relationships with patients’ families and care givers, primary care physicians, hospitalist, specialists, social workers, other case managers and nurses, acute and post-acute facilities, home health care companies, and health plans.

• This position will focus on health promotion for a senior population providing onsite hospital visits communicating and coordinating care with hospitalist/hospital staff and patient providing appropriate level of care recommendation (inpatient vs observation), using our internal charting system to report daily inpatient updates and working with hospital team on a expeditious discharge planning to next level of care. The acute care nurse will anticipate the need for post-acute and/or long-Term care, from day one (1) of hospital stay, providing support to all parties involved. Daily updates in our charting system are required for each patient using the hospitals EMR system and onsite reviews.

• Acute Care Nurse will be following the patient throughout the continuum of care when patient discharges to a Skilled Nursing Facility (SNF) or Long-Term Care (LTC) to provide weekly updates on discharge and ensure that upon discharge patients is connect back to the care of the primary care provider. Acute Care Nurse will provide warm hand off to the Community Care Nurse when patient is discharged to home and/or from post-acute care facilities.

• The Acute Care Nurse adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance and policies and

  ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

• Identifies appropriateness of inpatient vs. observation status

• Identifies areas of opportunities regarding proper allocation of healthcare resources in an acute and post-acute setting.

• Identifies and manage safety risk (complete a social assessment), identify functional status (ADLs and PT needs), discuss medications and self-management, identify and correct knowledge deficits.

• Hospital bedside discussion explaining our Care Management/Disease Management program with verbal introduction to their Community Care Manager for home visit once discharge to home from either inpatient or skilled nursing facility (SNF).

• Implements the ACM Coaching program with the appropriate patient population.

• Identifies from day one (1) of hospital stay any barriers for a safe discharge back to the community

• Seeks assistance from ChenMed’s Specialists when needed to support the care of our patients in healthcare facilities.

• In markets as appropriate, when patient in SNF, in conjunction with the post-acute physician, coordinates the transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed.

• Facilitates discharge to appropriate level of care and preferred providers

• Communicates discharge to all stakeholders including patient, patient’s family or designee, PCP, Center Manager and Community Care Nurse.

• Documents the appropriate date that the patient is medically discharged and update as appropriate.

• Social Determinates of Health (SDoH) screening with each patient on every admission and communicate to our Community Social Workers or PCPs when a need is identified.

• Identifies new diagnosis during acute stay and provide PCP documentation to review and add to patient problem list.

• Contacts the center manager or designee to arrange for a 4-day follow-up PCP appointment prior to discharge and whenever possible, communicate this information to the patient/caregiver.

• As appropriate, offers and discusses with patients’ the benefit of our CCM or DM programs and identify patient interest in participation.

• Coordinates acute UR physician meetings

KNOWLEDGE, SKILLS AND ABILITIES:

• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.

• Critical thinking skills required.

• Ability to work autonomously is required.

• Ability to monitor, assess and record patients’ progress and adjust and plan accordingly.

• Understanding utilization review and how to leverage with inpatient staff for possible reduction of medical cost on long length of stay patients.

• Ability to plan, implement and evaluate individual patient care plans.

• Knowledge of nursing and case management theory and practice.

• Knowledge of patient care charts and patient histories.

• Knowledge of clinical and social services documentation procedures and standards.

• Knowledge of community health services and social services support agencies and networks.

• Organizing and coordinating skills.

• Ability to communicate technical information to non-technical personnel.

• Proficient in Microsoft Office Suite products including Excel, Word, PowerPoint, and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software.

• Ability and willingness to travel locally, regionally, and nationwide up to 10% of the time.

• Spoken and written fluency in English, bilingual preferred.

• Associate degree in Nursing required.

• EDUCATION AND EXPERIENCE CRITERIA:

• Bachelor’s Degree in nursing (BSN) or RN with bachelor’s degree in a related clinical field preferred.

• A valid, active Registered Nurse (RN) license in State of employment required.

• A minimum of 2 years’ clinical work experience required.

• A minimum of 1 year of utilization review and/or case management, home health, hospital discharge planning experience required.

• A minimum of 1 year of case management experience in acute case management or community case management experience highly desired.

• This position requires possession and maintenance of a valid driver's license.

• Certified Case Manager certification is preferred. Certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN) desired.