Registered Nurse - Care Manager

The Care Manger position is an integral part of the healthcare team working closely coordinating inpatient and outpatient care and services across the continuum of care assuring and including Primary care and Specialty providers. The Care Manager utilizes his/her skills to coordinate internal and external resources to facilitate appropriate resource management of an age specific patient population which spans from newborns to geriatrics, identifying opportunities for process improvement, high risk cases and sentinel events, to the achievement of an acceptable outcome.  The Care Manager’s role in data collection, analysis and summarization supports performance improvement/quality programs, risk management, clinical pathway development and outcome measurement using guidelines.  They possess the ability to work independently as well as collaborate and communicate effectively with colleagues, supervisors, service delivery partners, other health care professionals and co-workers to build and maintain effective, dynamic professional team relationships.   This position is an integral part of the Patient Centered Care team. The Care manager works under the supervision of the Regional Director- Patent Centered Care Management to support the objectives of UVM Health Network - CVPH and the Medical Home. Responsible to identify at-risk patients and develop plan of care based on risk and patient goals to meet individual health needs through communication and assisting with access to resources to promote quality, cost-effective outcomes across the continuum of care.

Position Insights:

• This is a regular part-time, 56-72 hours per pay period position
• Salary Range: $32.14/hour-$47.57/hour
• $10,000 Sign-On Bonus for 1 Year Committment (pro-rated for part-time)

1. Respect for patient values, preferences and expressed needs:

• Customize care of each patient, ensuring that it’s culturally and literacy level appropriate.
• Understand patient preferences and optimize care as circumstances change.
• Assess, plan, coordinate and evaluate at-risk patients to promote healthy living with emphasis on prevention, self- management and behavioral changes to reduce hospital admissions and utilization of emergency department.

2. Care coordination and integration:

• Utilize a multidisciplinary approach for the patient’s care to promote a heightened focus on the patient needs/preferences.
• Identify and implement a Patient centered multidisciplinary care plan.
• Gather information necessary to accurately assess and address patient needs and work with multidisciplinary team to develop and monitor individualized patient centered plan of care based on risk and patient goals.
• Promote dialogue between patients and providers helping to guide them through the continuum of services and assist with transition from hospital to home/alternate level of care settings.
• Support patients to better self-manage chronic conditions to include: interact with pharmacist related to medications when required; identification of barriers, behaviors, etc. to promote healthy living.
• Provide education to patients and their families about care plan, importance of follow-up with providers, risk factors, monitoring of symptoms, medication management and available resources.
• Coordinate resources and referrals as identified.
• Establish and maintain effective working relationships with health care providers.

3. Interviewing, information gathering and education coordination.

• Understanding, educating and communicates to the patient the importance of Patient Centered care.
• Integral role that patients participate in creation of their plans of care in their overall health   

             and wellbeing.

     -      Patients participation, in easy-to-understand terms creating there to overall plan of care.

• Tailor communication to reflect patients’ needs IE: open ended questions to gain insight into the patient concerns or preferences required.
• Provide, during the process, options of care. Shared decision allows the patient values and preferences first, discussing the pros and cons of treatment options.
• Offer educational material, so patients can choose appropriate treatments to facilitate autonomy, self-care and health promotion.

4. Physical comfort:

• Ensure that the patient is physically comfortable to promote and be actively engaged in patient-centered care as it relates to the following;
• Pain management
• Assistance with activities of daily living
• Familiar with hospital surroundings and their environment.

5. Emotional support and alleviation of fears and anxiety:

• Evaluate anxiety associated with illness which decreases wellbeing
• Understand how this illness intervenes their overall wellness and family.
• Evaluate anxiety regarding the financial impact of their illness.

6. Encourage family and friends in the patient experience:

• Provide accommodations for family and friends.
• Involve family and close friends in the decision making process.
• Support family and friends as the caregivers to this patient.

7. Continuity and transition of their care when going home/alternate level of care :

• Evaluate and provide opportunities for patient to express concerns about their ability to care for themselves after discharge.
• Obtain, but not limited to, insurance authorization for discharge needs.
• Provide information regarding medication, physical limitations, dietary needs, DME, etc.
• Provide a coordinated approach to the continuum of care with outside services once discharged; IE: Home Care Agency, Rehab services, Transitions of Care, Specialty/PCP, etc.
• Refers patients appropriately for Adult homes, Sub Acute, Nursing facilities, Acute Rehab and Hospice as appropriate, etc. Completing PRI if required for these facilities
• Provide information related to anticipated services and the associated cost of those services.

8. Access to care when it is needed once they are home and in the ambulatory setting.

• Provide information related to access to care once they are discharge.
• Work with community based organizations, Primary Care physician’s offices, Specialty physician offices, etc., to assure a seamless continuum of care.
• Assure that appointments at discharge are scheduled for the patient prior to discharge.
• Coordinate and assist in following through with Primary care and specialty appointments.
• Work with the patient/family and other agencies to assure transportation to appointments is available post discharge.
• Promote healthy lifestyles and improved services throughout the communities served by the Medical Home. Duties include but are not limited to:
• Provide education to promote healthy lifestyles across populations in the community
• Provide care management supports to patients identified as high risk by the practitioner or meeting criteria for Health Home eligibility to ensuring patients are connected and utilizing community resources for self- management of their disease states.

9. Maintain skill competency.
10. Demonstrate commitment to continuing education.
11. Comply with HIPAA and UVM Health Network CVPH confidentiality policies.

Other duties as assigned.

1. Currently licensed as a Registered Nurse in New York State required.

2. Three years of nursing experience required, CCM preferred, Discharge Planner preferred.
3. Preferred experience in ambulatory care and/or case (care) management.
4. Knowedgable in the Managed care process preffered.
5. Knowlegdable of regulatory requirements; IE: DOH, CMS,EMTALA, Joint Commission, etc.
6. Knowedgable in Medicare, Medcaid, Private insurances, etc., preferred.
7. Knowledge of electronic medical records systems; IE: Sorian, Medent, Care Navigator, EPIC, Microsoft applications, etc.
8. Ability to develop and maintain effective relationships with staff, providers, patients and external customers. Good interpersonal and communication skills.
9. Ability to understand and commit to UVM Health Network CVPH core values of teamwork, confidentiality and quality care.
10. Working knowledge of medical terminology and medications required.
11. Knowledge and understanding of prior authorization for DME/Medications, etc.
12. Must have strong verbal and written communication skills. Must have excellent attention to detail.
13. Ability to effectively manage multiple cases and projects required. Assessment, goal setting skills, project management skills, and problem solving skills required.
14. Ability to make appropriate decisions with a minimum amount of supervisory direction required.
15. Ability to incorporate evidence based practices required.
16. Ability/experience with data collection, program management and reporting required.

As applicable, the individual has training/competency in attending to the special needs and/or behaviors appropriate to the age of the patients for which care is being provided.