Case Management Nurse

Springfield, MA - Chestnut Medical Associates

Job Schedule: Full Time

Standard

Hours:

Exempt - 40 hours a week

Job Shift: Shift 1

Reports to: Program Manager for Care Management

The Outpatient Nurse Care Manager is responsible for managing the complex patients that are included in the risk contracts. They are responsible for the management of care for this defined group of patients including complex care management, disease management, transitions of care, as well as coordination of care.

Major responsibilities include accurately identifying patients for care management, developing individualized plans of care, providing education, assessing/addressing barriers to care, medication reconciliation, medication titration as well as ensuring adherence to quality measures. The goal is to work with patients to optimize control of chronic conditions, improve functional status, reinforce self-management plan, and prevent/minimize long-term complications as well as to avoid unnecessary emergency room visits or hospital admissions.

They will work collaboratively with providers and other health team members along the patient’s continuum of care and are available to patients and families for care coordination/education through face‑to‑face visits, home visits, if necessary, as well as telephonic interactions. In addition, they will assist with advance directives, palliative care, hospice, and other end‑of‑life care coordination. Appropriate documentation in patient medical records and/or care management application is required and is vital.

Care management program metrics including total medical expenses, emergency room utilization, hospital admission/readmission data will be reviewed on a regular basis to measure program impact. Assumes accountability for own professional practice and for aspects of patient care delegated to others. Practices within the ethical and legal parameters of nursing practice. This description covers the essential functions of the position. Incumbent is expected to perform other similar and related duties as assigned.

Adheres to system and department compliance policies, and all applicable laws/regulations.

• Responsible for coordinating and providing care that is safe, timely, effective, efficient, equitable, and patient-centered to the patients in the risk contracts.
• Responsible for appropriately identifying patients for care management utilizing multiple sources including provider referrals, referrals from transitions of care, health plans as well as complex lists of patients from the ACO.
• Conducts whole person assessments to determine individual patient needs and create individualized self‑management plans of care in conjunction with the patient/family. Evaluate the effectiveness of the plan of care and revise as necessary to meet goals.
• Assists patients to make informed decisions about their care by acting as their advocate regarding their clinical status and treatment options.
• Promotes quality and cost‑effective interventions and outcomes to patients in collaboration with primary care providers or specialists.
• Manages transitions of care for patients discharged from the hospital, emergency room, or from a skilled nursing facility. Responsible for reviewing the discharge summaries, follow up on testing that is pending, ensure ordered services are in place. Outreaching to the patients to perform a medication reconciliation, ensure patients understanding of discharge instructions and assess for further care management needs.
• Provides disease management/complex care management to patients face to face or telephonically as well as utilizing technology that becomes available. Provides home visits to patients, when appropriate. Titrates medications via protocols, when necessary.
• Assists with advance directives, referrals to palliative care/hospice when appropriate, and other end‑of‑life care coordination.
• Oversees population management activities with the Care Coordinators which includes addressing quality indicators that are out of range and assisting patients to reach targets.
• Accountable for remaining current with knowledge of care…