Position Purpose: Coordinates and manages care for the high and rising risk population through multiple care delivery systems, supporting patient in self-management of their health.
Coordinate and manage care of high risk population
Complete telephonic outreach and home visits as applicable based on patient acuity.
Performs a comprehensive care management assessment of patient needs to ensure optimal health outcomes.
Develops a self-management action plan of care, coordinates services and navigates the patient through the health care system with a goal of enabling the patient and family to effectively manage their condition(s) and optimize outcomes.
Coordinates effective transitions of care and effective handoffs to the next level of care across the entire continuum.
Collaborates with the patients care team including but not limited to hospital team, primary care team, specialists, home care, SHCN clinical programs, and any others involved with patients care and approved by the patient to ensure effective coordination of services and full understanding and execution of the care plan.
Maintains required medical documentation for care management activities in the system's care management module (electronic medical records), according to the standards of work.
Follows standards of work and consistently maintains department established caseloads and timeframes for case completion.
Documents and reports all quality and patient safety events by recording and adhering to all of Steward Health Care Network's safety reporting guidelines.
Performs other duties as assigned
Evaluates processes, identifies problems, and proposes improvement strategies to enhance the delivery of care for patients throughout continuum of care.
Escalates any barriers to positive outcomes to supervisor and/or manager same day
Participates in the refinement of and development of new standards of work.
Maintains awareness of key performance indicators/metrics and manages caseload through appropriate management of medical expenses. Coordinates interventions to prevent adverse events such as ED visits, hospital admissions, and readmissions.
Attend staff meetings and education offerings both in person and via teleconference as required
Education / Experience / Other Requirements
Graduate of a state-approved school of nursing.
Bachelors of Science in Nursing (BSN) preferred.
Years of Experience:
Possess a current unrestricted RN license
Must maintain Basic Life Support (BLS) certification.
Certified Case Management (CCM) or CCM eligible strongly preferred.
Work Related Experience:
Experience educating patients and families with self-management
Creation and implementation of patient-centered care plans
Utilization of motivational interviewing when engaging patients/families
Knowledge of chronic disease management
Understanding of Medicare and Medicaid regulations
New England Sinai Hospital And Rehabilitation Center