Care Manager - Care Transformation

Job Information  Exemption Status:
Non-Exempt    A Brief Overview  The Care Manager serves in an expanded nursing role to collaborate with patients and their health care team including Primary Care Providers, specialists, and hospitals to provide a model of care that ensures the delivery of quality, efficient and cost-effective healthcare services across the continuum. The Care Manager functions as a coordinator of patient care, assesses, plans, implements, monitors, and evaluates all options and services with the goal of optimizing the patient's health status.

The Care Manager integrates evidence-based clinical guidelines, preventative guidelines, protocols, and other metrics in the development of transitions of care plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare for the targeted high-risk population. The Care Manager monitors patients across the health continuum with a focus on effective and safe transitions through the healthcare system with a goal to optimize resources and reduce avoidable readmissions back to acute care.

The Care Manager manages performance feedback metrics to further refine the care model to maximize clinical, quality, and fiscal outcomes for the targeted population. The delivery of professional nursing care at Stormont-Vail Health Care is guided by Jean Watson's Theory of Human Caring and the theory of Shared governance, both of which are congruent with the mission, vision, and values of the organization.
Education Qualifications
* Bachelor's Degree Bachelor's of Science in Nursing (BSN)

Preferred Experience Qualifications
* 2 years Nursing experience in an acute or ambulatory setting. Required
* Case/care management experience. Preferred

Skills and Abilities

* Demonstrates prudent professional and clinical judgement, effective problem solving skills, critical thinking, excellent organizational and interpersonal skills, creativity, flexibility, and the ability to multi-task.
* Demonstrates ability to be self-directed and purposeful in seeking the necessary knowledge and skills to enhance professionalism in order to provide high-quality care.
* Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.
* Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
* Demonstrates ability to work autonomously and be directly accountable for practice.
* Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, priority setting, and work organization.

Licenses and Certifications
* Registered Nurse - KSBN Required
* Basic Life Support - BLS Required within 90 days of hire.

What you will do
* Actively participates with clinic redesign and Patient Centered Medial Home (PCMH) expansion. Collaborates with primary care staff, social work staff, and other care team members to ensure optimal care coordination for the patient.
* Establish and maintain a supportive, collegial role with primary care practices engaged in improvement activity, particularly including assigned practices and their individual improvement team members.
* Initiates communication with patients upon learning they have been identified as high risk / targeted population.
* Pulls data from multiple systems and merge together to create a complete performance picture related to targeted populations. Implements interventions based on data and established guidelines. Monitors data for trends and individual outliers. Analyzes data for process improvement opportunities to impact patient outcomes.
* Optimizes patient care transitions by: o Assuring an appropriate post-acute plan and utilization of services o Assisting the post-acute team in development of an appropriate discharge plan for post-acute discharge. o Assures collaboration with primary care, social work & PCP care manager, other care team members, and community supports to ensure optimal care coordination for the patient.
* Guides patients through the health care system o Facilitates interaction and communication with health care staff providers. o Provides disease/treatment specific education to both patients and families o Oversees scheduled appointment(s) o Oversees patient testing and admissions o Reviews patient records o Efficiently documents medical…