Inpatient Discharge Care Manager

Community Health Network of Connecticut•Wallingford, CT

About The Position

Community Health Network of Connecticut, Inc. (CHNCT) is seeking an Inpatient Discharge Care Manager in the Greater New Haven, Connecticut area. The role collaborates with hospitals, primary care providers, home health agencies, members, and CHNCT Intensive Care Managers to identify clinical and social factors contributing to readmissions and develop comprehensive discharge plans. The manager meets with hospitalized members to assess barriers to safe discharge, including physical needs, cognitive deficits, psychosocial needs, and gaps in outpatient support. The role also provides health education and information about HUSKY Health and community resources, communicates care gaps and discharge barriers, and helps develop outpatient strategies for follow-up care and social needs. The position includes face-to-face hospital visits, comprehensive assessments, multidisciplinary care planning, coordination of alternatives to acute care, and communication with members, representatives, providers, and hospital care coordinators. The manager discusses anticipated discharge plans with relevant providers within two days of admission, participates in collaborative meetings, initiates referrals, and refers Quality of Care issues to Quality Management. The role also maintains collaborative relationships, applies referral criteria, supports care planning for members at risk of ED overutilization or readmission, and maintains knowledge of CHNCT, ASO, community, vendor, and Medicaid benefit programs.

Requirements

Minimum of two years of direct clinical care experience as an RN.
Current and unrestricted RN license; an active Registered Nurse License is required.
State motor vehicle license.
Strong verbal and written communication skills.
Excellent organizational skills and ability to manage multiple priorities concurrently.
Strong critical-thinking and problem-solving skills.
Ability to work independently and in a team environment.
Tact and diplomacy when handling highly sensitive information and issues.
Strong computer and keyboard skills.
Flexibility in covering assignments.
Two to four years of post-secondary schooling desired.
Associate's degree desired; Nursing is the desired major.

Nice To Haves

Bachelor's degree preferred.
Case Management experience preferred.
Knowledge of Medicaid regulations preferred.

Responsibilities

Collaborate with hospitals, PCPs, home health agencies, members, and CHNCT Intensive Care Managers to identify clinical and social determinants contributing to readmissions and develop comprehensive discharge plans.
Meet with hospitalized members to assess barriers to safe discharge, including physical needs, cognitive deficits, psychosocial needs, and gaps in outpatient support.
Provide health education and information about HUSKY Health and community resources.
Communicate care gaps and barriers to safe discharge with hospital care coordinators, attending physicians, ICMs, and PCPs.
Partner with the care team to develop outpatient strategies, including appropriate follow-up with physicians and specialty providers, care in the appropriate setting, and attention to social determinants.
Complete face-to-face visits with members in the hospital.
Conduct comprehensive assessments of member history and current presentation to identify needs and develop multidisciplinary interventions.
Explore and coordinate alternatives to acute care and communicate recommendations to attending physicians, members or authorized representatives, and hospital care coordinators.
Discuss anticipated discharge plans with inpatient providers, PCPs, ICMs, and outpatient providers within two days of admission.
Participate in internal and external collaborative meetings.
Initiate referrals as necessary.
Identify and refer Quality of Care issues to the Quality Management department.
Develop and maintain collaborative relationships with internal constituents and hospitals/providers, and interact successfully with business partners.
Use referral criteria to triage members to appropriate CHNCT departments.
Collaborate on reviews of members at risk of ED overutilization or readmissions and work with the care team to formulate plans.
Maintain knowledge of CHNCT programs, other ASO and community programs, vendors, and covered Medicaid program benefits.
Perform other duties as assigned.