Coordinated Care Manager PD

Summary:
The Coordinated Care Manager reports to the Manager of Coordinated Care Management or the Director of Care Management/Clinical Social Work. Provides coordinated care support to Physician leadership and Clinical Manager(s) of respective services. Participates in daily rounds and collaborates with the clinical healthcare team across the patient care continuum to include pre-admission and post hospital discharge. Provides oversight of the progress of a specific patient population. Collects data and facilitates clinical quality improvement (CQI) teams to enhance the quality and cost effectiveness of patient care and prevent readmissions.

 

Responsibilities:
Partners with medical staff and other members of the healthcare team in collaboration with the patient/family to facilitate the plan of care for a defined patient population across the continuum of care.
Identifies a high risk patient population within the caseload for care management assessment screening and targets interventions in conjunction with the healthcare team within one business day of patient admission.
Emergency Department Care Coordination Manager; ensures the appropriate level of care is assigned to patients upon admission. Responsible for the identification of Medicare Beneficiaries that require Hospital Issued Notices of Non Coverage (HINN) or Advance Beneficiary Notices (ABN). Responsible for delivery of appropriate notices as indicated and advises patient of appeal rights and care options.
Proactively builds post hospital referrals and sends to the Transition Care Coordinator when indicated to facilitate timely discharge.
Delivers Important Message follow-up notices to all Medicare patients according to CMS regulations
Collects data on all readmitted patients and incorporates findings into post acute plan of care in collaboration with members of the healthcare team. Research includes follow-up calls to skilled nursing facilities home health care agencies and acute rehabilitation facilities.
Participates in daily care rounds to collaborate with members of the patient�s healthcare team as well as to evaluate and facilitate development and implementation of the discharge planning process. Develops the initial patient discharge plan and reviews with patient family members and other members of the interdisciplinary team. Reassesses the discharge plan daily during collaborative care rounds.
Advocates for the patient and advises the patient regarding financial implications of their discharge plan when coordinating care for the patient. Communicates the discharge plan including post facility/agency acceptance to patients families and all members of the care team. Documents final discharge disposition in progress notes.
Develops appropriate patient care reports to ensure safe patient handovers occur as a patient is transferred from one patient care area to the next.
Provides care plan direction for the advancement of a patient care delivery system which supports managed care strategies and decreases readmission risk. Acts as a change agent by identifying opportunities to improve patient flow and reduce service delays through problem resolution and follow-up. 
Promotes patient satisfaction by facilitating patient participation in education programs patient care paths and by conducting post-discharge follow-up including making phone calls to select patients and family members.

 

Other information:
BASIC KNOWLEDGE:

Masters Degree preferable in Nursing (concentrations in health services administration health education business administration are acceptable).
Consideration will be given to internal candidates committed to completing their Master�s program.
Center Case Management (CCM) � board certification or Accredited Case Manager (ACM �) is highly desirable.
Current licensure to practice as a Registered Nurse in the State of Rhode Island



EXPERIENCE:

Five (5) years of relevant clinical experience that includes recent experience with care management patient navigation case management or discharge planning is strongly preferred.
Must exhibit strong interpersonal skills and a collaborative approach and style of communication in order to interact successfully on as daily basis with a wide and diverse population of both health care providers patients and their families.
Familiarity with InterQual� care management criteria is required.
Must demonstrate knowledge and skill necessary to provide care to patients throughout the life span with consideration of aging processes human development stages and cultural patterns in each step of the care process.
A basic proficiency in the use of Microsoft office software programs including email and outlook calendar and basic keyboard skills are also required.



WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS:

General hospital environment with occasional stressful conditions associated with patient care.
Risk of exposure to blood borne pathogens and communicable disease is minimized and controlled by adherence to Hospital Infection Control policy and procedures.
Must be able to make hospital rounds through various patient care areas either by walking or through some other mobile means.
Visual acuity and finger dexterity is needed to review medical records navigate through automated system screens and type on a typical computer terminal keyboard.
Must be able to lift and or carry up to 10 lbs. in order to transport items from one patient care unit to the next.



SUPERVISORY RESPONSIBILITY: None

 

Lifespan is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status.   Lifespan is a VEVRAA Federal Contractor.

 

Location: Rhode Island Hospital USA:RI:Providence

 

Work Type: Per Diem

 

Shift: 1

 

Union: UNAP