Inpatient Discharge Care Mgr.- Rural Health

Community Health Network of Connecticut, Inc.•Wallingford, CT

1d•$70,500 - $94,000•Remote

About The Position

Community Health Network of Connecticut, Inc. (CHNCT) is currently seeking an Inpatient Discharge Care Manager – Rural Health. The Rural Health Transformation (RHT) Program is a federal grant that empowers states to strengthen rural communities across America by improving healthcare access, quality, and outcomes by transforming the healthcare delivery ecosystem. This role provides care coordination support for eligible HUSKY Health members residing in rural areas, collaborating with various stakeholders to address clinical needs and access barriers that may contribute to readmissions. The position involves meeting with members inpatient to assess factors impacting safe transitions of care, providing health education, and developing outpatient strategies as part of comprehensive discharge plans.

Requirements

Minimum 2 years direct clinical care experience as an RN is required.
Strong verbal and written communication skills.
Excellent organizational skills, ability to manage multiple priorities concurrently.
Demonstrates strong critical thinking and problem-solving skills.
Ability to work independently and in a team environment.
Uses tact and diplomacy for highly sensitive information and issues.
Team player.
Strong computer and keyboard skills.
Flexible in covering assignments.
RN license must be current and unrestricted.
Current and unrestricted motor vehicle operator's license and reliable transportation.
Active Registered Nurse License
State Motor Vehicle License

Nice To Haves

Case Management experience preferred.
Knowledge of Medicaid regulations preferred.

Responsibilities

Provide care coordination support for eligible HUSKY Health members residing in rural areas.
Collaborate with hospitals, primary care providers, home health agencies, members, caregivers, and the CHNCT care team to identify and address clinical needs and access barriers that may contribute to readmissions.
Meet with members while they are inpatient to assess factors potentially impacting a safe transition of care, including physical needs, cognitive limitations, psychosocial needs, and gaps in primary care or community-based support services.
Provide health education and information on available HUSKY Health and community resources to members.
Collaborate with the health care team to develop an outpatient strategy that includes proper post-acute follow up care as part of a comprehensive discharge plan.
Complete face-to-face visits with members while in the hospital.
Conduct comprehensive assessments through member interviews and review of available clinical information including member history and current presentation to identify needs and develop multidisciplinary interventions.
Explore and coordinate appropriate alternatives to acute care and communicate recommendations to attending physician, member/authorized representatives, and hospital care coordinator to facilitate appropriate and timely action.
Discuss anticipated discharge plans with the inpatient providers/PCP, CHNCT care team and outpatient providers.
Initiate referrals as necessary.
Participate in internal and external collaborative meetings.
Provide cross coverage of post-discharge follow up activities for members recently discharged from the hospital or emergency department including conducting the assessment and implementing member-centric, transitions of care interventions.
Identify and refer Quality of Care (QOC) issues to the Quality Management department.
Perform other duties as assigned.
Develop and maintain collaborative relationships with internal and external constituents including hospitals/providers.
Successfully interact with business partners.
Utilize referral criteria for triage of members to appropriate CHNCT departments.
Collaborate to review members with potential ED over utilization risks and readmissions and work with the care team to formulate plans to address.
Maintain knowledge of CHNCT programs, other ASO and community programs, vendors, and covered benefits for the Medicaid programs.