Coordinated Care Manager

Reports to the Director Care Management or designee. Provides coordinated care support to Physician leadership and Clinical Manager(s) of respective services. Makes daily rounds and collaborates with the clinical healthcare team across the patient care continuum to include pre-admission and post hospital discharge. Participates in the 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.


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 1 business day of patient admission.
Proactively builds post-hospital referrals and sends to the Transition Care Coordinator to facilitate timely discharge.
Delivers Important Message follow-up notices to all Medicare patients according to Centers fo Medicare & Medicaid Services (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.
Performs 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.
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:

Bachelor� degree in Nursing with current license to practice as a Registered Nurse in the State of Rhode Island.
Master�s degree preferred.
Center Case Management (CCM) � board certification or Accredited Case Manager (ACM �) is highly desirable.


Five (5) years of clinical experience that includes recent experience with care management patient navigation case management or discharge planning is strongly preferred.
Must exhibit strong interpersonal skills as well as a collaborative approach and style of communication in order to interact successfully on a 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 Outlook calendar and basic keyboard skills are also required.


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.



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: The Miriam Hospital USA:RI:Providence


Work Type: Full Time


Shift: 2


Union: Non-Union