Consulate Health Care Transitional Care Nurse (Case Manager) in Staunton, Virginia
Job ID 112919
Position Location US-VA-Staunton
Care Center Kings Daughters Community Health & Rehab
Job Category RN
Position Location : Street 1410 N. Augusta St.
Position Location : Zip 24401-2401
Position Status FT is 35+ HOURS WK
Purpose of Your Job Position
As a employee, you are entrusted with the responsibility of carrying out your daily tasks and assigned duties.
You are expected to provide innovative, responsible results with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. The primary responsibility of the position is to provide directive and expertise through comprehensive assessment, planning, implementation, coordination and overall evaluation/monitoring of the care of the patient. The overall goal of the position is to enhance the quality of patient management and satisfaction, to promote continuity of care and cost effectiveness through the integration and functions of case management, utilization management and discharge planning. This position works closely with the interdisciplinary team in order to provide quality patient outcomes while managing medical resources effectively.
The Transitional Care Nurse (Case Manager) is responsible for the identification, development, implementation, and evaluation of best practice initiatives designed to improve the health, access to care and reduce cost for the population served. The Case Manager provides clinical leadership for the Managed Care, Bundle Payment and ACO programs by serving as an educator, role model, member advocate, to enhance patient care and staff competency. The Case Manager collaborates with other departments (including Clinical Staff, Administration, Directors, Managers, and others), to evaluate, coordinate and direct activities and programs in support of delivery of patient care. The Case Manager oversees daily team operations and provides strong leadership through training, coaching, teaching, and managing patient case load. This job description does not list all the duties of the job. You may be asked by supervisors or managers to perform other duties. You will be evaluated in part based upon your performance of the tasks listed in this job description. The employer has the right to revise this job description at any time, for any reason.
Duties and Responsibilities
Serves as the Clinical Lead over concurrent review, case management with MCOs, ACOs, and Hospitals case management teams. Establishes relationships with the Case Managers, Medical Directors to promote the facilities participation in these programs.
Oversees multiple health care center’s case management needs as assigned. Will average between 35 and 50 patients per week.
Works with a multidisciplinary team to develop and implement an up-to-date care plan.
Management and Assessment of Quality/Efficiency Indicators
Oversee the data collection process as needed by Payors, ACOs and bundled payments.
Review the information and identify and highlight successes and identify and take action on areas needing improvement.
Serve as the lead for review of Payor, ACO, bundled payment quality/efficiency reports and work with the Care Center’s teams as needed to improve scores.
Will be responsible for improving the Quality/Efficiency scores as deemed necessary to align with payor’s, ACO’s, and bundled providers requirements for participation.
Responsible for the identification of opportunities and threats that may impact meeting payor’s/ACO’s Quality/Efficiency scores.
Responsible for leading Care Centers to meet or exceed required scores.
Responsible for notifying supervisor and ED of barriers to meet scores.
Prepares select cases for physician, utilization management, and quality review as needed.
Assess adequacy of discharge plan and addresses any risk associated with discharge with internal associates and external case managers, PCP’s and others designated to care for the patient.
Complete assessments; address any identified barriers to compliance across the continuum.
Develop care plan and interventions with patient and family input, physician, clinical team and referral source as appropriate.
Proactive post discharge follow-up; telephonically for a minimum of 30 days following discharge.
Coordination of post discharge care with primary care physician or appropriate designee.
Interact in a collegial and collaborative fashion with health plan, ACO, Health Center’s clinical staff to include: RNs, Social Workers, UR/UM, physicians, and nonclinical support staff
Communicate regularly with patients and families, clinical team, defined referral source, primary care provider and document regularly in required systems for outcome reporting
Promote cost effective health care with aligned health system networks
Function as a member of a self directed team to meet specific individual and team performance metrics
Telephonic discussion with health care providers, managed care organizations, ACOs and defined referral sources to obtain and/or to explain benefit coverage determinations and to provide and/or obtain additional clinical information
Identification of metrics to measure performance of health outcomes, efficient utilization and access to care and overall cost.
Develop, implement and maintain systems, policies and procedures for the collection and analysis of performance metrics
Establish consistent reporting and review process to ensure effective communication and collaboration with Managed Care Organizations, ACOs, defined Referral Sources, , Medical Director and physicians as appropriate
Define and utilize clinical protocols to refer patients to the appropriate specialist for diagnosis or treatment
Help patients and their families in obtaining referrals to a specific specialist
Review and ensures the appropriateness and adequacy of all therapy and clinical assessments of patients.
Communicates frequently with the attending physician, interdisciplinary team and health plan to advocate for the patient to ensure appropriate level of care and safe care transitions.
Collaborates effectively with the patients health care team to establish an optimal cost effective plan while inpatient and transitioning to the next level. The health care team may include physicians, health plan UM/CM Nurse, hospital discharge planners, referral coordinators, etc.
Consults with the Physician and health plan to resolve any barriers in the patient’s movement along the continuum of care.
Completes daily review of census and prioritizes work in order to effectively manage assigned case load.
Reviews with the ED and other key department’s monthly readmission reports, quarterly and other reports as needed to assist with the identification of opportunities for improvement.
Participate in rounds with attending physicians for all managed care, bundled payment and ACO patients when possible.
Directs the Utilization Review meeting related to managed care, bundled payment and ACO patients weekly.
Document and notify any/all changes in level of care and communication with health plan timely.
Provide clinical and therapy updates as required per company contracts timely, documenting continued stay approval.
Perform other business related duties as assigned.
- Must possess, as a minimum, a Degree in Nursing.
Must have, as a minimum, two (2) year’s experience in a hospital, nursing care facility, or other related health care facility.
Must have a working knowledge of managed care rules, regulations, and guidelines.
Must have comprehensive knowledge of managed care, health insurance, and Case Management.
Ability to negotiate coverage and provide complete and timely case management, bundled payment and ACO reports.
Prior experience with a Health Plan, private or third party case management company preferred.
Must be a leader, able to navigate a complex environment, with excellent verbal and written communication skills.
Ability to effectively interact and establish immediate credibility with all levels of management, physicians, and community leaders.
Effective influencing, negotiation, relationship-building and communication skills are essential.
Ability to work effectively under pressure, due to change of priorities.
Ability to facilitate the integration of the clinical, finance, operations, and strategic functions of the organization.
Possess strong leadership, critical-thinking and motivational skills/abilities.
Knowledge of post acute healthcare delivery and management.
Ability to adapt quickly to changing conditions while managing multiple priorities.
Ability to work independently, self-direct activities.
Excellent organizational skills.
Ability to work effectively and establish and promote positive relationships.
Must possess a current, unencumbered, active license to practice as an RN/LPN in this state.
Must possess a demonstrated knowledge of case management; managed care, Medicare, utilization management practices, insurance benefits, and cost management strategies.
Must possess knowledge of and demonstrate competency in ensuring compliance with Medicare and third party reimbursement, criteria/levels of care.
Must possess demonstrated negotiation and prioritization skills.
Must have the ability to work in a matrix reporting system.
Must be a supportive team member, contribute to and be an example of teamwork and team concept.
Must be able to read, write, speak, and understand the English language.
Must possess the ability to make independent decisions when circumstances warrant such action.
Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.
Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to managed care and nursing facilities.
Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.
Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care.
Works in office areas, as well as throughout the facility.
Moves intermittently during working hours.
Is subject to frequent interruptions.
Light travel between assigned facilities.
Communicate with all department personnel
Works beyond normal working hours, weekends and holidays and on other shifts/positions as necessary.
Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).
Attends and participates in continuing educational programs as related to changes and new initiatives with case management and managed care.
Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants.
Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and AIDS and Hepatitis B viruses.