OutPat Nurse Care Mgr

BAYCARE HEALTH PARTNERS INC•Northampton, MA

7d•$94,775 - $128,225•Onsite

About The Position

The Outpatient Nurse Care Manager manages complex patients covered by risk contracts. The role coordinates complex care management, disease management, transitions of care, and other care coordination to help patients control chronic conditions, improve functional status, follow self-management plans, and avoid unnecessary emergency room visits or hospital admissions. The Nurse Care Manager identifies patients for care management, conducts whole-person assessments, develops individualized care plans with patients and families, provides education, addresses barriers to care, reconciles and may titrate medications, and supports adherence to quality measures. The role collaborates with providers and other members of the health team across the patient’s continuum of care. Patient and family support may be provided through face-to-face visits, home visits when appropriate, and telephone or available technology. Responsibilities also include managing transitions after discharge from a hospital, emergency room, or skilled nursing facility; reviewing discharge information and pending tests; ensuring ordered services are in place; and assessing follow-up needs. The position may assist with advance directives, palliative care, hospice, and other end-of-life care coordination. The Nurse Care Manager documents care in patient medical records and/or care management applications, oversees population-management activities with Care Coordinators, and reviews program metrics such as total medical expenses, emergency room utilization, and hospital admissions and readmissions. The role is accountable for professional practice and delegated aspects of patient care, follows the ethical and legal parameters of nursing practice, and adheres to system and department compliance policies and applicable laws and regulations. Other similar and related duties may be assigned.

Requirements

Associate degree in Nursing.
At least 5 years of experience as a Registered Nurse.
Massachusetts Registered Nurse license.
Driver’s license.
CPR certification.
Strong communication, interpersonal, and problem-solving skills to advocate for optimal patient outcomes.
Ability to work closely with patients, providers, provider office staff, and managed care plans.
Strong organizational and prioritization skills.
Attention to detail and ability to work independently.

Nice To Haves

Bachelor’s degree in Nursing.
2 to 3 years of care-management experience.

Responsibilities

Coordinate and provide safe, timely, effective, efficient, equitable, and patient-centered care to patients in risk contracts.
Identify patients for care management using provider and transitions-of-care referrals, health plans, and ACO patient lists.
Conduct whole-person assessments and develop individualized self-management plans with patients and families; evaluate and revise plans as needed.
Advocate for patients and help them make informed decisions about clinical status and treatment options.
Promote quality and cost-effective interventions and outcomes in collaboration with primary care providers or specialists.
Manage transitions of care after discharge from a hospital, emergency room, or skilled nursing facility, including reviewing discharge summaries, following up on pending testing, and ensuring ordered services are in place.
Contact patients after discharge to reconcile medications, confirm understanding of discharge instructions, and assess further care-management needs.
Provide disease management and complex care management face-to-face, by telephone, and using available technology; conduct home visits when appropriate.
Titrate medications using protocols when necessary.
Assist with advance directives, palliative care and hospice referrals, and other end-of-life care coordination.
Oversee population-management activities with Care Coordinators, address out-of-range quality indicators, and help patients reach targets.
Maintain current knowledge of care management, population management, community resources, and quality-improvement methodologies.
Document appropriately in patient medical records and/or care management applications.
Review care-management program metrics, including total medical expenses, emergency room utilization, and hospital admission and readmission data.
Maintain accountability for professional practice and delegated aspects of patient care, and practice within ethical and legal nursing parameters.
Adhere to system and department compliance policies and applicable laws and regulations.
Perform other similar and related duties as assigned.