Integrated Care Intensive Care Manager RN

Eskenazi Health • Indianapolis, IN

100d

About The Position

The Intensive Care Manager, RN through home visits, will serve as a coordinator of care, collaborating in tandem with other members of the Care Integration Team, physicians, nursing, interdisciplinary team, and patients/families to provide seamless and efficient services for those within their assignment. This position functions as a Care Manager, providing assessments, demonstrating problem solving and critical thinking skills, and practicing effective decision making. This position is M-F 8-4:30pm and is conducted out in our community via home visits.

Requirements

• Current Indiana licensure as a Registered Nurse required.
• Three years of clinical nursing experience required.
• Demonstrates knowledge of the case management, patient education and care coordination process.
• Demonstrates effective communication skills, knowledge of disease processes, and normal growth and development for all age groups, in order to ascertain an accurate understanding of the patient's symptomology.
• Competency in interpersonal, written/verbal communication and negotiation skills.
• Demonstrates diplomacy, flexibility and professionalism.
• Ability to network cohesively with the interdisciplinary team.

Responsibilities

• Proactively contributes to Eskenazi's mission: Advocate, Care, Teach and Serve with special emphasis on the vulnerable population of Marion County.
• Models Eskenazi values of Professionalism, Respect, Innovation, Development and Excellence.
• Serves as a coordinator of care, collaborating with other members of the Care Integration Team, physicians, nursing, interdisciplinary team, and patients/families to provide seamless and efficient services for those within their assignment.
• Provides face to face, home, or telephone visits to address patient's needs and performs follow up calls to assigned patient population.
• Monitors disease control and psycho-social indicators; works with the patient's primary care team to ensure medications and lifestyle treatment goals are being reached.
• Collaborates with patient/family, sets realistic step-by-step goals to reduce specific chronic disease and psycho-social indicators.
• Serves as an integral part of the care team to mitigate long-term medical and financial risks from poorly controlled chronic diseases.
• Independently functions as a Care Manager, providing assessments, demonstrating problem solving and critical thinking skills, and practicing effective decision making.
• Demonstrates knowledge of pathophysiology, pharmacology and disease processes for the assigned population, and age-appropriate care.
• Communicates with physicians, interdisciplinary team, nursing and patients/families to ensure timely patient progression through the episode or plan of care.
• Resolves problems impeding diagnostic or treatment progress.
• Strategizes to ensure proper utilization of resources within the targeted population.
• Interviews patients; collects and assesses specific information in an attempt to identify individual needs and develop a comprehensive plan of care that addresses medical, social and financial needs.
• Collaborates with the Director of Ambulatory Integrated Care and Director of Inpatient Integrated Care, as well as the Physician Advisor to identify cases that require special intervention.
• Actively participates in creating an action-oriented and time specific plan of care.
• Ensures adherence to clinical pathways/protocols and the appropriate use of clinical tools through collaboration with physicians, interdisciplinary team, nursing, community health workers, Integrated Care Coordinators and Transition of Care staff.
• Reassesses and monitors patients for change in condition warranting initiation of a clinical pathway and alteration in plan of care.
• Documents processes and care plan information in medical record appropriately.
• Monitors the plan of care for assigned patients and collaborates with other members of the Care Integration team for planning.
• Educates physicians, interdisciplinary team, and nursing, regarding payer sources and the role this plays in transition planning.
• Communicates with on-site private payer/managed care case managers.
• Evaluates active funding for each patient and communicates with Financial Counseling to facilitate the initiation of appropriate funding applications.
• Addresses financial barriers to healthcare/medical compliance with the patients and families when indicated.
• Provides education to patients/families that are adapted to their unique needs, lifestyle, and socio-economic situations.
• Educates and informs patients of community resources that are located within their neighborhood community.
• Advocates for vulnerable patients and participates in assessing their needs for health care services and community programs.

What This Job Offers

• Job Type: Full-time
• Industry: Hospitals
• Education Level: Bachelor's degree