Provide Care Management services to a contracted community based high-risk population. Contracted population currently includes members of the following: Medicare Advantage Plans, Physician Provider Networks, and Employer Plans. Goal is to promote quality cost-effective outcomes for assigned caseload. Care Manager performs face-to-face ongoing clinical and psychosocial assessments to identify needs, set goals and monitor client. Assessments are performed by telephone, in the home, at the hospital, at the THN Care Management office and at the member?s job site. Individualized plans of care developed to facilitate self-management skills of a health condition and improve function and quality of life for high-risk members. Hands-on health education and chronic disease monitoring will be performed. Care Management Coordinator will advocate for appropriate resources available in the community, and across the continuum of care to best meet needs of the client. Care Management Coordinator will interact with all levels of personnel, medical staff, patients, community resources, providers and families.
Talent Pool: Nursing
Coordinates care provided to a community based population. Conducts thorough screening and ongoing physical and psychosocial assessments on community based caseload of patients in a timely manner per policy. Consistently collaborates with patient/family, physicians and other health care team members to identify physical and psychosocial issues or barriers that affect health condition management. Implements a comprehensive patient-cantered plan of care to proactively manage these issues and improve the patient's health status. Prioritizes caseload to balance patient and departmental needs. Acts as a patient advocate and communication link with other health care providers and community resources. Advocates for the patient as needed to resolve benefit issues. Follows the CMSA National Case Management Standards of Care.
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Develops individualized plans of care. Thoroughly assesses each patient's eligibility for needed resources. Stays abreast of community resources and refers the patient for services and assistance when appropriate. Willingly collaborates with health care team members to formulate an individualized care plan and goals that best meet the needs of the family/patient. Utilizes motivational interviewing techniques to engage patients in goal setting. Updates care plan appropriately as goals are met and plans are revised. Consistently documents accurate and timely information in Electronic Medical Record as per policy.
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Monitors patient adherence to treatment plans. Consistently monitors adherence to the patient's treatment plan and relays issues to appropriate care providers promptly and effectively. Proactively identifies barriers to adherence and acts promptly to revise the treatment plan to improve patient adherence and outcomes. Takes prompt action when issues involving the appropriate and cost effective utilization of resources are identified, collaborating with appropriate health care team members. Confers with the patients, physicians and other care providers and insurance carriers in the role of patient advocate, as needed to resolve benefit issues and secure necessary services.
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Provides documentation of community case management activities. Consistently documents all community care management activities in the Electronic Medical Record using the established format in a timely and accurate manner. Promptly sends reports to physicians and other providers as per policy and as needed to relay pertinent finding. Maintains accurate accounting of work hours and miles driven to conduct THN Care Management business activities and submits in a timely manner. Actively participates in program improvement activities.
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Provides health education. Consistently communicates with the health care team members to ensure patient care needs are addressed promptly. Effectively educates patients as well as other members of the health care team regarding health care benefits, insurance and managed care issues. Considers teaching methods based on individual needs/differences. Provides health education to patients and family members to assist in disease management and the development of coping skills. This includes information on disease processes, medications, treatment plans and preventive measures. Follows-up to evaluate the effectiveness of education provided. Initiates and facilitates patient care conferences in in-patient and home settings as needed. Willingly precepts nursing students to meet the needs of students, patients, and the department. Consistently and accurately documents activities in the Electronic Medical Record as per policy. Appropriately updates departmental leadership with necessary information. Assists in program development and group education. Mentors other staff members in developing the community case manager role.
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EDUCATION: Required
Associates Degree in Nursing with comparable experience in case management (in lieu of BSN) may be considered.
Preferred
Bachelor's Degree in Nursing
EXPERIENCE: Five years as a Healthcare-Registered Nurse; five years related acute care experience and/or home care experience combined. Clinical knowledge and ability to educate clients of all ages about the following core disease management issues: Diabetes, Hypertension, Hyperlipidemia, CAD, Asthma and COPD required.
LICENSURE/CERTIFICATION/REGISTRY/LISTING: REQUIRED
RN | RN license
PREFERRED
Certified Case Manager (CCM)
