Ambulatory Case Manager

Cape Cod Healthcare•Hyannis, MA

12d

About The Position

The Ambulatory Case Manager will exhibit a commitment to the organization's mission and goals, working collaboratively and incorporating continuous quality improvement. This role involves tracking and managing inpatient high-risk admissions, avoidable ED visits, readmissions, and high-cost utilization for PHO members. The Case Manager ensures the appropriate delivery of services through assessment, problem identification, coordination, planning, monitoring, and evaluation. They will facilitate service delivery by building relationships with healthcare providers, health plans, facilities, and community resources to ensure appropriate utilization across the continuum of care. Effective communication with members, families, caregivers, physicians, and other healthcare personnel is crucial, adapting communication style to members' varying educational, background, and cognitive levels. The role requires empathy, compassion, and a vested interest in member wellness, working with members on realistic goal setting while considering socio-cultural and ethnic factors. The Case Manager will accommodate member preferences for patient education and coaching modes (telephonic, in-person, video conferencing), initiate in-person visits based on established standards, and assess home environments for risks and barriers, making appropriate referrals. Adherence to and adjustment of the plan of care based on member status and reassessment is essential. Collaboration with other disciplines (PCP, Specialists, Dietician, VNA, SNF/Rehab, community resources) is required, including participation in multi-disciplinary case conferences and evaluation of care effectiveness. The Case Manager will reassess the plan of care at regular intervals and discharge members when goals are met, notifying the PCP and other providers of significant changes. Documentation in case management systems, including a collaborative plan shared with the clinical team, must be timely, clear, concise, and adhere to PHO protocols for performance and success measures. Maintaining medical record confidentiality is paramount. Regular meetings with the PHO Helping Hands team and Medical Director for collaboration and support are expected. The role requires maintaining core/clinical competency and current knowledge of regulatory and payer requirements, participating in PHO committees and education programs, and demonstrating flexibility, cooperation, and teamwork. Collaboration with hospital-based Case Managers on large case management and discharge planning is also a responsibility, along with performing other related duties to support the organization's mission.

Requirements

Current license as a Registered Nurse in the Commonwealth of Massachusetts.
Minimum of 3 years of experience in a hospital setting, home health care or outpatient Physician Office setting.
Demonstrate recent knowledge/experience within the past 3 to 4 years in: Discharge Planning; Utilization/quality management; Home care and/or Hospice Nursing.
Ability to speak effectively before individuals and groups of patients or employees of the organization.
Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor, with patients, physicians, fellow employees, and insurance companies.
Excellent organization and time management skills.
Possess skills in independent decision-making, problem-solving, independent judgement, use of critical thinking and effective communications.
Ability to work independently and effectively in a fast-paced environment.
Ability to work productively in a stressful environment and effectively handle multiple projects and changing priorities.
Proficient computer skills with the ability to utilize and integrate information from multiple software and EHR systems.

Nice To Haves

Bachelor of Science Degree in Nursing preferred.
Certificate in Case Management preferred.

Responsibilities

Gathers and analyzes specific criteria and guidelines to track and manage inpatient high risk admissions, avoidable ED visits, readmission and high cost utilization of the PHO members.
Ensures the appropriate delivery of services through Assessment and Case /Problem Identification, Coordination, Planning, Monitoring and Evaluation.
Facilitates the delivery of services by establishing relationships with all health care providers, health plans, facilities and community resources insuring appropriate utilization across the continuum of care.
Communicates in a clear and effective manner with members, their families, caregivers, physicians and other health care personnel.
Communicates in a clear and effective manner with members of varying educational levels, backgrounds and cognitive levels.
Shows empathy and compassion in case managing our members; makes every effort to understand the circumstances affecting the member and their health care and vested interest in the wellness of the member.
Works with the members on realistic goal setting while incorporating socio-cultural ethnic factors, support and facilitate members to move towards achieving their goals.
Accommodates the member’s preference for mode for patient education and coaching such as telephonic, in-person or video conferencing.
Initiates an in-person visit with the member based on established case management standards of care and protocols.
Assess the member’s home environment to identify potential risks and barriers to the health and wellness and makes appropriate referrals as needed.
Adheres to defined plan of care and adjusts the plan as appropriate based on the member’s status and information collected upon reassessment.
Collaborates with, and is responsible for, coordination with other disciplines participating in the Plan of Care (i.e. PCP, Specialist, Dietician, VNA, SNF/Rehab personnel, community resources). Participates in multi-disciplinary patient case conferences; evaluates the effectiveness of patient care.
Reassesses the plan of care at regular intervals and discharges the member when goals are met.
Notifies the Primary Care Physician (PCP) and other care providers in a timely manner of significant changes in the member’s condition or care plan.
Documents the member’s care in the case management systems including the development of a collaborative plan to be shared and updated with the risk member’s clinical team such as the PCP and/or Specialists.
Documentation is timely, clear, concise, and addresses specifics of teaching and care coordination.
Follows the PHO’s documentation protocols to collect pertinent data supporting performance and success measures.
Maintains medical records and medical information in a confidential manner appropriate to legal requirements and standards of good practice.
Regularly meets with the PHO Helping Hands team and the Medical Director as needed for care collaboration, coordination and team support.
Maintains core/clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities.
Participates in PHO-related committees, education programs, in-services, and meetings as required.
Demonstrates flexibility, cooperation and characteristics of a team member.
Collaborate with Case Managers at Hospitals on large case management and discharge planning.
Performs other related duties as assigned or requested to meet the scope of the organization’s mission.