Nurse Care Manager

What You’ll Do

Position Summary

The Nurse Care Manager will work with Suvida Healthcare’s multidisciplinary care team to providehigh qualitycare for our high-risk patients. They will collaborate with their multidisciplinary neighborhood center care team to develop organization-wide approaches to problem solving, tracking, and managing complex cases and populations. This nurse will need to plan effectivelyin order tomeet patient needs,identifysocial determinants of health, manage chronic conditions, and promote efficientutilizationof resources.

The Nurse Care Manager will implementSuvida’scare pathways for patients with chronic conditions. They will also oversee transitions of care for patients to ensure safe transitions from acute to post-acute care, by coordinatingtimelyand cost-effective care. The Nurse Care Manager will overseehighly complexand resource intense patients within their assigned care team.

They will collaborate with all providers, care team, patients, caregivers, payers, community resources, and external providers to promote quality of care.

Responsibilities

• Oversees chronic care and transitions of care management of high-risk patients within their care teams and neighborhoodcenters

• Serves as a resource to the multidisciplinary team for the management of complex patients, including chronic care management assessments and care plans.

• Performs triage for patients via phone and addresses issues appropriately or forwards message to appropriatepartyfor further interventions.

• Responsible for ensuring efficient, organized patient transitions from acute and post-acute setting to home or other transitional care facility.

• Perform comprehensive assessments for both physical, mental, and social risk factors that support individual patient needs whileidentifyingand addressing barriers.

• Collaborates with medical staff, nursing staff, and ancillary staff toeliminatebarriers to efficient delivery of care in theappropriate setting.

• Coordinates/facilitatespatient care progression throughout the continuum.

• Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated patients; monitors the patient’s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis: completion and reporting diagnostic testing, treatment plan and discharge plan; modification of plan of care, as necessary, to meet the ongoing needs of the patient; communicates relative information to the care team; assignment of appropriate levels of care; completion of all required documentation

• Coordinates and communicates with providers and all involved care team members in the discharge plan to ensure their participation and readiness.

• Ensures that all elements critical to the plan of care, including discharge plans, have been communicated to the patient/family and members of the healthcareteamand are documented as necessary toassurecontinuity of care.

• Knowledgeable of the Four Elements of the Coleman Model

• Coordinates post-discharge needs with providers, such as Durable Medical Equipment, Home Health needs, medications, and other supplies.

• Proactivelyidentifies/resolvesissues impeding diagnostic, treatment progress, and discharge.

• Schedulespatientfor follow up with PCP or specialist within 7 days of discharge.

• Reconcilesdischarge medication andworkswith PCP and clinical pharmacist for review post-discharge.

• Reviews and evaluatespatientto ensure that the patient meets criteria for home health admission or admission to other transitional care institutions.

• Tracks and monitors readmissions to acute care facilities andassistswith re-hospitalization reduction initiatives.

• Works withclinicalteam toestablishcare programs to help prevent readmissions and hospitalizations.

• Obtains patient medical records from acute care facilities, including orders, referrals, care team documentation, diagnostic testing results, and acute care visit summaries.

• Utilizes advanced conflict resolution skills as necessary to ensuretimelyresolution of issues.

• Identifiesat-risk populations using approved screeningtooland follows established reporting procedures.

• Refers cases and issues to clinical leadership teamand follows up asindicated.

• Refersappropriate casesfor social work intervention asneeded .

• Collaborates/communicates with external case managers. Initiates andfacilitatesreferrals for home health care, hospice, medicalequipmentand supplies.

• Activelyparticipatesin clinical performance improvement activities.