Nurse Care Manager - Per-diem

Northwestern Medical Center•St. Albans, VT

3d•Onsite

About The Position

Northwestern Medical Center (NMC) is recruiting for a Nurse Care Manager in Case Management. This per-diem position primarily involves working hours from 8:00 a.m. to 4:30 p.m., generally including one weekend per month. NMC's mission is to provide exceptional healthcare to its community, and this role is part of a high-reliability team that values its employees. The position is part of a bargaining unit represented by a labor union, with wages, benefits, and terms governed by a collective bargaining agreement. The Nurse Care Manager will conduct individualized concurrent clinical evaluations of patients, assess their health needs and concerns, review medical records for medical necessity, develop personalized action plans, provide education, and issue referrals for post-acute care. They will monitor patient progress, modify care plans, and provide clinical information to health insurers. This role involves working closely with an interdisciplinary care team and technology to identify high-risk, complex cases, manage care, provide care planning, referral management, post-discharge planning, and coordinate community-based and transitional care. The Nurse Care Manager will develop strong team-oriented relationships with healthcare professionals, evaluate patient health outcomes, and partner with the team to facilitate optimal patient care. Key responsibilities include directing the discharge planning process, assisting with transitions from inpatient to post-discharge care, involving patients and caregivers in transition planning, advocating for decreased hospital stays when appropriate, guiding and advocating for patients and families in navigating the healthcare system, and coordinating community resources. Maintaining accurate and timely patient records and working in a fast-paced environment with minimal supervision are also essential.

Requirements

Graduate of an accredited school of licensed practical nursing or registered nursing with current licensure as a Registered Nurse or Licensed Practical Nurse in the State of Vermont.
Three years in a hospital &/or clinic setting preferred.
Utilization management and/or case management, community care management experience preferred.
Certified Case Manager preferred.

Nice To Haves

BSN or MSN strongly preferred.
Three years in a hospital &/or clinic setting preferred.
Utilization management and/or case management, community care management experience preferred.
Certified Case Manager preferred.

Responsibilities

Conduct individualized concurrent clinical evaluations of patients, their health needs, and concerns.
Review patient medical record for medical necessity.
Develop personalized action plans.
Provide education and issue referrals for post-acute care.
Monitor patients’ progress in meeting established goals and modify care plans accordingly.
Provide clinical information to health insurers as required.
Work closely with interdisciplinary care team and technology to identify high-risk, complex patient cases.
Manage care, provide care planning, referral management, post-discharge planning, and coordinating community-based and transitional care.
Develop a cohesive and strong team-oriented relationship with physicians, nurses, and other healthcare professionals.
Evaluate and report on patient health outcomes and work in partnership with interdisciplinary healthcare team to facilitate the best in patient care.
Direct discharge planning process in support of treatment adherence and medication compliance.
Assist with transitions for patients discharged from an in-patient hospital to post-discharge care.
Include patients and caregivers in transition of care planning.
Advocate for decreased hospital stay when appropriate.
Guide, intervene and advocate on behalf of patients, their caregivers and/or families regarding navigating and comprehending the healthcare system.
Coordinate resources in the community to ease transition.
Maintain accurate and timely records of all patient-related interactions.
Collaborates with internal staff and outside agencies to meet the needs of the patient and their families.
Collaborates with DCF/APS for issues regarding children and vulnerable adults and files appropriate reports as required by law.
Assists patients of all ages to provide information on resources/services available.
Utilizes community service providers to maximize the patient's ability to function in the community.
Makes appropriate referrals to social service agencies related to financial concerns for adult patients.
Supports patients and families during times of transition.
Coordinates support for post partum mothers and their infants.
Provides information to patients and families regarding end of life care and options.
Supports the emotional needs of patient/family when discussing and/or planning placement in a skilled nursing facility or other long-term care solution respecting feelings regarding their loss of independence.
Supports emotional and clinical needs of chronic disease management, as well as diagnosis.
Participates in discharge planning and Care Coordination.
Assists patients with identifying support systems and services post discharge.
Coordinates with & contributes to inpatient discharge planning activities to ensure patients’ needs are being met, roadblocks/barriers to discharge are addressed, appropriate services/supports are offered.
Communicates with long-term care facilities and home health agencies to facilitate transition back to community setting.
Provides information to patient and family that is age specific and appropriate for their level of understanding.
Acts as a liaison between provider and patient/family to answer questions, clarify issues, and gather information.
Provides information to patients/family to improve their understanding of medical recommendations.
Conducts patient record review to determine appropriateness of admission based on established criteria.
Communicates with providers to ensure appropriate level of care, efficient use of resources, payor requirements, and plans for discharge.
Collects data related to LOS, denied days, resource consumption and patterns and explores strategies to manage utilization and decrease variation.
Updates insurance providers as needed regarding plan of care.