CMRN-Ambulatory Nurse Case Manager; MNA

CMRN-Ambulatory Nurse Case Manager (MNA)

Join to apply for the CMRN-Ambulatory Nurse Case Manager (MNA) role at Atrius Health
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Explore opportunities at Atrius Health, part of the Optum family of businesses. We’re an innovative healthcare leader, delivering an effective system of connected care for adult and pediatric patients at 28 practice locations in eastern Massachusetts. Our team of physicians, primary care providers and clinicians work with hospitals, community specialists and nursing facilities. Be part of our vision to transform care and improve lives by building trust, understanding and shared decision‑making with every patient.

Join us and discover the meaning behind Caring. Connecting. Growing together.

Responsible for providing on‑site transitional care coordination to ensure safe transitions of care and optimal communication between treating facility, patient/family and Atrius Health. Coordinate patient transitions from hospital to home or other care settings, ensuring a smooth discharge process and continuity of care.

• Provides direct referral source servicing at identified facility, building and enriching relationships, identifying needs, problem solving and meeting or exceeding expectations of external customers
• Serves as an extension of the Atrius Health practice site, connecting with Atrius Health patients and/or families to bridge the Atrius Health practice to the patient.
• Conducts review of the medical record for Atrius Health adult medical or surgical hospitalized patients.
• Conducts initial assessment of patient within 24–48 hours (business days of admission).
• Subsequent review/progress note at least every 7 days or accompanying a change in condition/plan.
• May provide educational and/or program material to the site facility staff in compliance with Atrius Health clinical initiatives, services and specialty programs.
• Performs needs assessments of patients/families for services including but not limited to primary care, specialty care visits, skilled homecare, palliative care, hospice care (including hospice residence), and/or skilled nursing facility, to ensure appropriateness of services and expedite transitions of care.
• Educates Atrius Health patients/families regarding provider relationships serviced through preferred homecare/SNF organizations.
• Assesses adult medical/surgical Atrius Health patients for risk of readmission, and communicates identified risks with transition of care, outpatient case manager and/or primary care team.
• Facilitates real‑time review of contributing factors to readmission of patients and explores opportunities for acute care hospitalization reduction.
• Accesses Atrius Health patient’s Epic medical record to determine current program enrollment for continuation of care.
• Assesses patients admitted with heart failure (HF) or chronic obstructive pulmonary disease (COPD) for HTM/RPM and initiates referral to the appropriate program.
• Initiates a referral to the Atrius Health heart failure program when appropriate.
• Collaborates with hospital‑based case manager to facilitate advance care planning documents such as health‑care proxy or MOLST form.
• Facilitates communication between patient’s hospital‑based care team and practice‑based primary care team when needed or requested.
• Collaborates with transition of care team and hospital‑based case manager to ensure post‑hospital follow‑up visit is scheduled.
• Provides supportive patient/family education for targeted diagnoses including heart failure, diabetes, COPD to ensure optimal preparation for home discharge.
• Coordinates with the hospital‑based case manager to facilitate regarding Atrius Health preferred provider networks.
• Seeks opportunities to improve communication and collaboration amongst all clinical partners in patient care, treating facility and internal/external partners or provider.
• Collaborates and communicates with Manager and Atrius Health Case Manager to identify and address any issues or concerns.
• Documentation:
  Maintains accurate records of the discharge planning process in the patient’s medical record for legal, regulatory, and billing purposes.
• Participates in service…