As a part of the Care Management Team the nurse (RN) will provide direct support to the healthcare team members, identifying complex patients or patients with targeted conditions who require care management, coaching, education, supervision, and/or support.
The nurse will evaluate appropriate level of care & services required, coordinate care, resources & services across the healthcare continuum to manage & improve the quality, effectiveness and cost of patient care.
Facilitate ongoing patient communications, review gaps in care, relevant outcome measures & post facility/discharge needs in collaboration with healthcare team members.
Facilitate the Clinical progression of the patient’s treatment and transition of care/discharge plans.
Oversees Interfacility Coordination & handoff between Acute & Post acute services.
Work closely with healthcare team to develop and execute patient care plans and coordinate communications & referrals with care team members & settings of care on behalf of patients.
Conducts assessments to identify at-risk patients and ensures individualized care planning for identified high-risk patients, utilizing clinical protocols where applicable.
Facilitate/Participate in interdisciplinary patient care rounds &/or conferences to review treatment goals, optimize resource utilization & progress through the continuum of care, treatment, providing education & plans supporting discharge needs.
In conjunction with the healthcare team, identifies strategies to improve the health literacy of the patient, family, and other caregivers as appropriate to promote patient engagement, self-management, and shared decision-making, communicating regularly with the patient and the patient’s caregivers to ensure the patient is able to adhere to treatment protocols.
Networks with local/community services to identify additional resources to support patients and their families.
Document in accordance with documentation guidelines and regulatory standards as well as provide hand-off patient information summaries to the next setting of care on the following: Patient/Member Engagement activities to include assessments, care plans, problems, goals, and interventions.
Team member coordination, collaboration & Supervision (LPN, CMA, SW)( where applicable).
Interfacility Coordination , collection & review of pre-admission documents, insurance information & transfer information.
Licensed Registered Nurse in the State of New Jersey.
Knowledge of Utilization Management Criteria Knowledge about PQRS, HEDIS, Meaningful Use, Patient-Centered Medical Home, or other quality metrics and tracking.
Knowledgeable about Population Health Management and clinical integration principles and processes.
Good working knowledge of benefit plans: HMO, Medicare, Medicaid, Employee, Commercial, Medicare Advantage, etc.
3-5 years hospital based or ambulatory care experience required
Experience with relevant systems (e.g., electronic medical records, disease registries). Word, Excel, Email, Allscripts, MCG, Sorian.
Professional Certification (CCM) preferred.