Registered Nurse - Care Manager

About Our Company

We're a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care.

Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians.

When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care.

Job Description

State Licenses:

Valid unencumbered NY & CT State RN License Required. Can allow for small grace period to obtain CT State License.

Position Summary:

The Nurse Care Manager participates in a dynamic interdisciplinary team, working closely with the Hospitalist, Post-Acute Care, Primary Care, Social Work, and other members of the care team to provide Care Coordination services to identified patients across the care continuum. The Nurse Care Manager will partner with patients and families in the transitions of care and/or longitudinal care setting, developing relationships which improve the patient experience. Utilizing clinical skills to identify barriers or gaps, the Nurse Care Manager will achieve goals of lowering costs and improving clinical outcomes by serving as an integral collaborative team member, managing assigned populations of post-acute and longitudinal patients, coordinating care by designing and implementing care plans focused on connectivity to primary and specialty care, reducing Emergency Department utilization; hospital admissions and readmissions; gaps in care; and/or at-risk status by ensuring completion of care coordination. Responsibilities may include patient outreach and engagement, coordination of clinical and non-clinical services, assessments, care planning, collaboration with external agencies, case conferences, home visits, self-management support and health coaching.

Essential Job functions:

• Works with interdisciplinary care team to facilitate seamless patient engagement and transitions across the continuum of care.

• Learns, understands, and successfully completes the Care Management and Transitions of Care process and workflow.

• Performs and ensures that assigned transitions of care (hospital/sub-acute, emergency room discharges) tasks in the EHR/care management platform are addressed in a timely manner within coding guidelines, applying care management concepts, principles, and strategies to assist the patient in achievement of patient-centered clinical treatment and Transition of Care goals.

• Utilizing established Care Management referral criteria (e.g., by risk status, cost, utilization, need, etc.), serves as a liaison to providers, patients, and families for coordination of services designed to optimize clinical and financial outcomes, collaborating with health plan partners, providers, practice staff and other healthcare team members in identifying appropriate patients for care management.

• Performs initial and periodic holistic assessments for care managed population. Formulates and implements clinical care management plan in collaboration with the primary care provider, specialist and/or other members of the care team (Social Work, Behavioral Health, Pharmacy, etc.) which address the patient's identified needs through assessing the patient/family needs, cultural diversity, health literacy, issues, resources, and care goals.

• Identifies and effectively utilizes community resources to meet the needs of patients/families, determining the choices available to individual patients, educating the patient/family on the choices available, prioritizing patients according to intensity, need and required follow up. Schedules follow-up appointments with primary care or a specialty department at Summit Health.

• Establishes a care management plan, mutually agreed upon by the health care team and the patient/family, which incorporates specific objectives with action-oriented interventions and self-management goals.

• Monitors and evaluates the progress of the patient while evaluating the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, issues, and goals, and communicates care plans status with members of care team, and patient/family.

• Collaborates with the healthcare team to revise the care management plan when changes occur. Initiates care conferences to discuss interdisciplinary care team responsibilities, patient progress, new problems, etc.

• Documents appropriately in the electronic health record, care management platform and any required patient tracking documents. Employs appropriate and timely use of tasking in the EHR. Maintains accurate and timely documentation. Ensures documentation meets current standards and policies.

• Maintains a working knowledge of Health Plan requirements. Develops collaborative working relationships with Health Plan case managers; negotiates on behalf of patient with third parties for cost-effective, high-quality services and to maximize the efficient use of resources.

• Demonstrates a broad understanding of Health Plan contracts (e.g., understanding patient attribution, care management requirements, clinical quality metrics, and utilization and cost outcomes).

• Ability to work with Health Plan-provided reports and data.

• Strives to meet established standards for productivity and care management metrics.

• Review's utilization and quality reports routinely and scans for gaps in care and to identify patients needing the additional support of care management.

• Participates in regular team meetings and peer review activities. Participates in departmental and organizational committees, as applicable.

• Participates in the orientation of new personnel. Precepts and mentors' peers. Promotes collaborative teamwork.

• Develops relationships across broad organizational lines and where innovative and unstructured situations arise.

• Performs all care management activities across the continuum of care while adhering to the core values of patient confidentiality, privacy, safety, advocacy, and adhering to ethical, legal, and accreditation/regulatory standards.

• Delivers care management services within the scope of licensure in accordance with Summit policy.

• Assumes accountability to changing patient and/or organizational priorities. Ability and willingness to self-motivate, to prioritize and change processes to improve effectiveness and efficiency. Adapts to changing patient or organizational priorities.

• Assumes accountability for the quality of care.

• Ability to manage conflict, stress and multiple simultaneous work demands effectively and professionally.

• Continually seeks new knowledge and learning regarding comprehensive primary care and chronic disease management.

• Other duties as assigned.

General Job functions:

Transitional Care Management:

• Performs follow-up calls for patients recently discharged from the emergency department or acute hospitalizations and considered at risk/high risk for admission/readmission.

• Collaborates with providers and other healthcare team members to include inpatient facilities, the patient's health plan, and health system administrators to facilitate transitions of care and care across the healthcare continuum and optimize clinical and financial outcomes.

• Ensures that all assigned transitions of care (hospital/sub-acute, emergency room discharges) tasks in the EHR/care management platform are addressed in a timely manner and within coding guidelines, schedules follow-up appointments with primary care or a specialty department at SMG.

Patient Identification and Management:

• Identifies patients through risk, need, cost, planned procedures, transitions of care, payer-provided data, care team/provider referrals.

• Performs full chart review considering chronic disease(s)/disease states/burden, risk factors, polypharmacy/pill burden, functional status, utilization, and social issues.

• Stratify risk or the process of categorizing patients and populations according to their likelihood of experiencing adverse outcomes (e.g., high risk for hospitalization) and into a risk category (high, moderate, or low) that reflects individuals' health conditions and needs. In this process, usually current and past healthcare resource utilization by clients is examined for predictability of health risk and potential future utilization of services.

• Identifies any gaps in care, engages care team through pre-visit chart prep or morning huddles to determine patient outreach and engagement to address/close.

Quality Improvement Initiatives:

• Participates in ongoing QA/QI initiatives to improve performance and patient outcomes.

• Demonstrates ability to compile patient data and prepare outcome analysis.

• Serves as a resource for all current and future quality improvement initiatives within Summit.

• Demonstrates ability to appropriately document and ensure that chronic HCC codes and HEDIS measures are appropriately utilized, and data discretely captured in the EHR.

Competency, Training and Education:

• Demonstrates knowledge of PCMH requirements and standards.

• Ability to implement the workflows specific to Care Management and Transitions of Care.

• Demonstrates the ability to effectively communicate and collaborate with care team members.

• Maintains core proficiencies /competencies as defined by the Care Management Program.

• Continually seeks new knowledge and learning regarding comprehensive primary care and chronic disease management.

• Self-motivation, focus, ability to work independently with effective time and task management.

• Willingness to establish effective working relationships with internal and external customers.

• Maintains a good working relationship within the department and with other departments.

• Ability to work well independently, while collaborating with other team members. Serves as a clinical resource person to staff.

Physical Job Requirements:

• Physical mobility, which includes movement from place to place on the job, taking distance and speed into account.

• Physical agility, which includes the ability to maneuver the body while in place.

• Dexterity of hands and fingers.

• Endurance (e.g., continuous typing, prolonged standing/bending, walking).

Education, Certification, Computer and Training Requirements:

• Bachelor's Degree preferred.

• Valid unencumbered NY & CT RN License Required.

• Valid Driver's License required & proof of valid vehicle insurance

• A minimum of 4 years Care/Case Management Experience or comparable clinical experience preferred.

• Certified Case Manager (CCM) preferred.

• Excellent written, verbal and listening community abilities. Communicate appropriately and clearly to staff and providers.

• Computer literacy, including data entry, retrieval, and report generation.

• Proficient Microsoft Office 365 skills required.

• Ability to work remotely.

• Able to work well in a virtual environment.

• Meet technical requirements to work remotely.

• Experience with standard office equipment (phone, fax, copy machine, scanner, email/voice mail) required.

Travel:

• Ability to drive to and from a variety of settings

• Ability to work with patients/families of all ages and in a variety of settings, including office, facility, and patients' homes, presenting diverse physical conditions and social/cultural environments.

• As needed for job requirements.

Pay Range $90,000 to $105,000

The provided compensation range is based on industry standards and salary determinations will be made based on numerous factors including but not limited to years of experience and location of position.

About Our Commitment

Total Rewards at VillageMD

Our team members are essential to our mission to reshape healthcare through the power of connection. VillageMD highly values the critical role that health and wellness play in the lives of our team members and their families. Participation in VillageMD's benefit platform includes Medical, Dental, Life, Disability, Vision, FSA coverages and a 401k savings plan.

Equal Opportunity Employer

Our Company provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to, and does not discriminate on the basis of, race, color, religion, creed, gender/sex, sexual orientation, gender identity and expression (including transgender status), national origin, ancestry, citizenship status, age, disability, genetic information, marital status, pregnancy, military status, veteran status, or any other characteristic protected by applicable federal, state, and local laws.

Safety Disclaimer

Our Company cares about the safety of our employees and applicants. Our Company does not use chat rooms for job searches or communications. Our Company will never request personal information via informal chat platforms or unsecure email. Our Company will never ask for money or an exchange of money, banking or other personal information prior to the in-person interview. Be aware of potential scams while job seeking. Interviews are conducted at select Our Company locations during regular business hours only. For information on job scams, visit, https://www.consumer.ftc.gov/JobScams or file a complaint at https://www.ftccomplaintassistant.gov/.