Care Manager

ROLE AND RESPONSIBILITIES

The role of the care management nurse is to coordinate continuity of care for patients and, as necessary, act as a liaison between the patient’s family, provider and healthcare organization, supporting the proper course of treatment at the appropriate time to maximize health and well-being.   Care Manager strives to promote self-managed care and the use of healthcare resources in the most cost-effective way possible, working with patients of all ages and conditions. The individual in this position has responsibility for overseeing the clinical plan of care to conform to evidence-based practice and regulatory requirements. This position integrates care coordination, utilization management, and discharge planning.

CORE FUNCTIONS

  • Identifies members appropriate for Care Management by use of targeted chronic conditions, level of care, and recognition of member’s disease specific and preventative measures, knowledge base or deficits in monitoring health, wellness and chronic conditions. Reviews and analyzes clinical indicators and whether there is any ‘gap’ in compliance that will result in member contact

  • Performs telephonic nursing assessments utilizing the nursing process

  • Assesses symptoms utilizing evidence-based tools to determine dispositions and comfort measures

  • Develops and implements the care plan

  • Monitors the care plan to determine if the goals are being met on an ongoing basis to evaluate for needed changes and updates the plan of care accordingly. Closes the plan of care when complete

  • Collaborates with Medical Director when appropriate (i.e., communicates review findings, criteria not met, use of alternative care settings, determination of appropriate level of care, delay of provision of services, etc.) to insure appropriate, coordinated service delivery

  • Identifies members requiring post hospital services and initiates discharge planning with attending physician and designated hospital personnel

  • Coordinates appropriate post hospital services

  • Conducts outbound calls to members to complete telephonic assessments and provide interventions and education for the management of their health, wellness and chronic conditions

  • Collaborates with the Provider or their designee to address the care plan from an integrated approach

  • Identifies and reports quality of care issues to the Medical Director and the VP of Medical Management

  • Communicates and collaborates with Medical and Nursing staff

  • Promotes the mission, philosophy, goals, and policies of the organization through staff education

  • Completes clear and concise documentation in Care Management programs

  • Participates in the quality care conference program

  • Provides clinical oversight of the care plan and care coordination process implemented by Care Coordinator

  • Maintain personal professional development

  • Collaborates with providers and/or the Medical Director when appropriate (i.e., communicates review findings, criteria not met, use of alternative care settings, determination of appropriate level of care, delay of provision of services, etc.) to insure appropriate, coordinated service delivery

  • Participates in departmental QIP process

  • Provides clinical oversight of the call coordination process initiated by the call coordinators

  • Active participant in the Care Integration Platform

  • Performs other duties as assigned

QUALIFICATIONS AND EDUCATION REQUIREMENTS

  • Must possess a current and active nursing license to practice in the state(s) assigned or maintain a compact license

  • RN license preferred

  • CCM highly desirable

  • 3+ years of various clinical experiences

  • Ability to quickly ascertain severity of illness

  • Ability to utilize nursing skills to understand and coordinate care of those members that are significantly physically compromised by their illness and/or disability

  • Accountable and autonomous

  • Ability to handle multiple demands of diverse workload and prioritizes critical issues

  • Ability to effectively communicate verbally and in writing

  • Ability to build effective collegial relationships

  • Ability to influence and effect change

  • Ability to analyze and think critically

  • Possesses current knowledge of disease pathophysiology, psychosocial issues, and treatment

  • Good time management skills

  • Positive, service-oriented attitude

  • High level of integrity

  • Computer literate

  • Must maintain valid driver’s license and vehicle

  • Able to develop, implement, communicate and evaluate a plan of care for each call

  • Ability to maintain a HIPAA compliant professional work environment


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