Population Health RN Inpatient Case Manager

NorthBay Healthcare Corporation•Fairfield, CA

13d

About The Position

The Population Health RN Inpatient Case Manager (PHRNICM) provides complex case management to diverse groups of high-risk capitated populations. The role coordinates care and services for members who need help navigating the healthcare system, facilitating appropriate delivery of care and services across the continuum and in collaboration with members, caregivers, medical home providers, and ancillary healthcare providers. Using a Population Health approach, the position helps identify populations, improve member engagement, coordinate care delivery, and improve clinical outcomes. The role also assists the inpatient case management department as needed. The PHRNICM identifies high-risk patients, assesses their medical, psychosocial, and financial needs, and develops individualized care plans that address goals, barriers, strengths, and available support. The position educates and advocates for patients and families, coordinates referrals and resources, supports communication among providers, and helps patients navigate transitions of care, including discharge from hospital to home or another care setting. The role remains involved until the patient reaches planned health goals, is discharged, or the case management function is transferred to outpatient services. The position also supports department quality monitoring and improvement, evaluates case management outcomes and operations, and communicates performance-improvement strategies to the UM Manager and Director of Care Management. It performs other duties as assigned to meet the needs of the population managed.

Requirements

Graduation from an accredited nursing school or college.
Bachelor of Science in Nursing (BSN) required.
Current California State RN License required.
Certified Case Manager (CCM) or Accredited Case Manager (ACM) certification required within two years of starting the position.
Minimum of two years of relevant clinical experience required.
Minimum of one year of case management experience required; equivalent case management education and/or experience will be considered.
Computer experience entering and retrieving data, knowledge of personal computers, and experience with Microsoft Suite—specifically MS Word—or good keyboard skills.
Ability to communicate effectively with patients, physicians, healthcare personnel, supervisory staff, and peers.
Ability to organize and prioritize assignments efficiently with minimal oversight and direction.
Willingness to research, learn, and obtain knowledge needed to perform the position.
Professional and courteous demeanor, with the ability to work independently and collaboratively while maintaining positive relationships.
Critical thinking and sound clinical judgment and assessment skills for decision-making.
Knowledge of NCQA, DHS, CMS, JCAHO, and EMTALA standards and federal and state regulations.
Knowledge of acute care, home care, subacute care, long-term care, hospice interventions, rehabilitation options, community resources, and related requirements.
Knowledge of Milliman and InterQual medical necessity guidelines.
Expert knowledge of CPT and HCPC codes and related guidelines.
Expert knowledge of ICE guidelines governing TAT, claims, and the denial process.
Knowledge of current healthcare standards and trends, best practices, management tools, and relevant resources and literature.
Knowledge of capitation and Managed Care legislation.
Knowledge of CMSA Standards of Practice.

Nice To Haves

Master’s degree in nursing or another health-related field preferred.

Responsibilities

Identify high-risk patients using referrals and information from the electronic health record and other sources, including the ED, Pharmacy, Hospital, and departmental or systems reporting.
Assess members’ needs and develop specific, comprehensive care plans addressing identified objectives, barriers, goals, and strengths.
Evaluate patients’ physical, behavioral, and social support capacities and their engagement with providers.
Follow up with patients and providers on identified healthcare needs and locate resources or coordinate multidisciplinary support to address concerns.
Manage referrals from referral specialists, providers, and care management staff to ensure identified healthcare needs and red flags are addressed.
Provide individual health education consultations and promote health awareness among individuals, groups, and organizations.
Provide specialized oversight, implement care plans, and educate patients in accordance with established policies and procedures.
Identify at-risk individuals and use clinical guidelines to develop comprehensive plans of care.
Obtain and evaluate relevant medical, psychosocial, and financial information through interviewing.
Advocate for patients and families throughout the episode of care and remain available to facilitate provider communication and monitor services.
Meet with patients and families when appropriate, involve them and their support systems in decision-making, and provide information about appropriate providers.
Collaborate with patients, families, physicians, and interdisciplinary teams to develop and update individualized plans of care.
Use processes to assess patients’ understanding and acceptance of proposed plans, willingness to change, and support for maintaining health behavior changes.
Apply teaching and learning theories to help patients and families address the physical and emotional effects of body changes and chronic illness.
Document and communicate with providers and care team members to minimize fragmented care and coordinate transitions, generally from hospital to home or community facilities.
Use problem-solving and conflict-resolution skills to provide consistent quality care.
Participate in department quality monitoring and improvement, including quality audits, training, and assigned projects.
Analyze and evaluate case management effectiveness in relation to patient outcomes, fiscal parameters, customer satisfaction, and system operations; communicate performance-improvement strategies to the UM Manager and Director of Care Management as appropriate.
Manage patient care through healthcare systems according to individual needs and collaborate with physicians and other providers on changes to care plans.
Develop comprehensive plans of care with physicians, Social Services, and the interdisciplinary team.
Track patient pathways through identification and assignment of DRG.
Communicate the anticipated discharge date to patients, families, physicians, and staff.
Proactively communicate with and assess and reassess patients throughout their episodes of care, developing alternative discharge plans when indicated.
Transition patients to the next appropriate level of care, involving Outpatient Case Management Services or other resources as appropriate.
Remain involved until the patient is discharged from the hospital or the case management function is transferred to outpatient services.
Perform other duties as assigned to meet the needs of the population managed.