CMRN-Ambulatory Nurse Case Manager (MNA)

Atrius Health•Newton, MA

23d•$40 - $75•Onsite

About The Position

Responsible for providing on-site transitional care coordination to ensure safe transitions of care and optimal communication between treating facility, Patient/Family and Atrius Health. Responsible for coordinating patient transitions from Hospital to home or other care settings, ensuring a smooth discharge process and continuity of care

Requirements

Bachelor of Science in Nursing or Bachelor’s degree in a related field required.
Current unrestricted RN licensure to practice professional nursing in the Commonwealth of Massachusetts required. Must be obtained if not currently practicing in Massachusetts.
Minimum 5 years nursing experience, which includes a minimum of 3 years in utilization management or case management.
Minimum of 3-5 years clinical experience with home health care experience or strong knowledge base in home health and hospice care
Extensive knowledge of patient care, medical treatments and clinical procedures, and use of electronic medical records (EMR).
Demonstrated proficiency using multiple software applications, including MS Office, EXCEL, Cloud based platforms and EPIC reporting workbench and dashboards.
Strong communication, critical thinking and problem-solving skills.
Ability to interpret clinical information, apply UM criteria and health plan guidelines for decision making.
Ability to work effectively in a faced paced team environment
Able to use all electronic tools and applications relevant to the performance of the duties of the position, including but not limited to phone, keyboard, computer and computer applications.
Able to work in multiple locations and cover multiple primary care practices as needed.
Performs all job functions in compliance with applicable federal, state, local and company policies and procedures. Accesses only the minimum necessary protected health information (PHI) for the performance of job duties. Actively protects the confidentiality and privacy of all protected health information they access in all its forms (written, verbal, and electronic, etc.) taking reasonable precautions to prohibit unauthorized access. Complies with all Atrius Health and departmental privacy policies, procedures and protocols. Follows HIPAA privacy guidelines without deviation when handling protected health information.

Nice To Haves

Certification in Case Management (CCM) or CCM eligible preferred.
American Heart Association Basic Life Support (BLS) strongly preferred.
Advanced Cardiac Life Support (ACLS) may be required based on specialty.

Responsibilities

Provides direct referral source servicing at identified facility, building and enriching relationships, identifying needs, problem solving and meeting or exceeding expectations of external customers
Serves as an extension of the Atrius Health practice site, connecting with Atrius Health patients and/or families to bridge the Atrius Health practice to the patient.
Conducts review of the medical record for Atrius Health adult medical or surgical hospitalized patients.
Conducts initial assessment of patient within 24 – 48 hours (business days of admission).
Subsequent review/progress note at least every 7 days or accompanying a change in condition/plan.
May provide educational and/or program material to the site facility staff in compliance with Atrius Health clinical initiatives, services and specialty programs.
Performs needs assessments of patients/families for services including but not limited to primary care, specialty care visits, skilled homecare, palliative care, hospice care (including hospice residence), and/or skilled nursing facility, to ensure appropriateness of services and expedite transitions of care.
Educates Atrius Health patients/families regarding provider relationships serviced through preferred homecare/SNF organizations.
Assesses adult medical/surgical Atrius Health patients for risk of readmission, and communicates identified risks with transition of care, outpatient case manager and/or primary care team.
Facilitates real-time review of contributing factors to readmission of patients and explores opportunities for acute care hospitalization (ACH) reduction.
Accesses Atrius Health patient’s Epic medical record to determine current program enrollment for continuation of care.
Assesses patients admitted with Heart Failure (HF) or Chronic Obstructive Pulmonary Disease (COPD) for HTM/RPM and initiates referral to the appropriate program.
Initiates a referral to the Atrius health heart failure program when appropriate
Collaborates with hospital-based case manager to facilitate advance care planning documents such as health care proxy or MOLST form.
Facilitates communication between patient’s hospital-based care team and practice based primary care team when needed or requested.
Collaborates with transition of care team and hospital-based case manager to ensure post-hospital follow up visit is scheduled.
Provides supportive patient/family education for targeted diagnoses including heart failure, diabetes, COPD to ensure optimal preparation for home discharge.
Coordinates with the hospital-based case manager to facilitate regarding Atrius Health preferred provider networks
Seeks opportunities to improve communication and collaboration amongst all clinical partners in patient care. treating facility and internal/external partners or provider
Collaborates and communicates with Manager and Atrius Health Case Manager to identify and address any issues or concerns.
Documentation: Maintains accurate records of the discharge planning process in the patient's medical record for legal, regulatory, and billing purposes.
Participates in service recovery as needed.
Promotes problem identification, resolution to barriers in care delivery, efficiency, productivity and customer satisfaction.
Builds relationships with physicians, referral sources, managed care and assigned facility(ies).
Provides information, resource materials and education to all providers and case managers and solicits feedback.
Promotes Atrius Health specialty programs designed to meet the needs of patients, providers, and partners.
Assists with other referral source account coverage as needed.
Performs other duties as requested.