Saint Francis Hospital is seeking an experienced Full-time RN Care Manager to join our team!
The RN Care Manager serves in an expanded nursing role to assure the provision of highly coordinated care for patients attributed to the accountable care organization (ACO) by collaborating with patients and their primary care providers to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. Identifies appropriate patients via risk stratification tools and electronic admission/discharge data. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient's health status while reducing healthcare costs. Integrates evidence-based clinical guidelines, preventive guidelines, protocols and other metrics in the development of treatment plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare for the assigned patient population. Performs transitional care management as well as longitudinal chronic care and disease management.
The ACO RN Care Manager is primarily a telephonic position with some travel to physician/provider practices and occasional home visits.
Additional Responsibilities include:
Identifies the targeted population within his/her assigned patient population and utilizes provided risk stratification tools and approved methods to prioritize needs and direct interventions. Assesses the healthcare, educational and psychological needs of the patient/family.
Designs an individualized plan of care with the patient and fosters a team approach by working collaboratively with the patient, family, primary care provider, and other members of the health care team to ensure coordination of services. Implements clinical interventions based on risk stratification and evidence-based clinical guideline adherence and promotes best practice by initiating/adjusting therapies as directed by the practitioner.
Provides appropriate follow-up and monitoring as needed.
Provides patient health and disease management education utilizing best practices for patient engagement and motivational interviewing process.
Coordinates referrals and other community resources.
Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.
Continuously evaluates laboratory results, diagnostic tests, utilization patterns and other metrics to monitor quality and efficiency results for assigned population.
Works closely with the practice care team and serves as a resource to the patient and healthcare team.
Adheres to administrative standards regarding patient confidentiality.
Maintains required documentation for all care management activities.
Collects required data and utilizes this data to adjust the treatment plan when indicated.
Works with ACO leadership to continuously evaluate process, identify problems and propose process improvement strategies to enhance the delivery of care model.
Reviews the current literature regarding effective engagement and communication strategies, care management strategies and behavior change strategies and incorporates into clinical practice.
Utilizes appropriate conflict resolution, assertiveness, negotiation and collaboration skills in facilitating patient throughout the health care continuum.
Perform chronic disease management including patient education and coordination of care with identification and navigation of patients to the high value, low cost providers in the community for their health care needs.
Provide transition of care management across the continuum with excellent communication/collaboration between stakeholders, including warm handovers, following best practices for optimal outcomes.
Utilize software and practice EMRs to ensure accurate documentation of care coordination including assessments, care planning, interventions and outcomes in accordance with the program's internal protocol.
Utilize real-time data from ACO-generated reports to track key performance indicators and identify areas of concern.
Assists in closing gaps in care for the quality metrics. Performs other duties as assigned within scope of practice.
BSN required, but will consider verified current enrollment in an accredited BSN program with evidence of successful progression; with demonstrated care coordination, patient education/disease management, and transition of care management experience.
RN license in the state of Delaware or compact license required. Additional RN licensure in the state of Pennsylvania preferred.
Three years' experience in clinical nursing, ambulatory care management, and managing Medicare patients required.
Home care or ACO care management experience preferred.
Case Manager Certification preferred, strongly encouraged after 1 year of employment
Valid driver's license and ability to travel to provider sites mainly in New Castle County, occasionally Kent and/or Sussex Counties and southeastern PA, depending on practice assignment, and to patient homes as needed.
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