Nurse Care Manager

SSM Health - Madison, WI3.8

30+ days agoFull-time

Role Purpose:
Under the general direction of the Director of Patient and Family Services/Care Management, performs those accountabilities relevant to using skilled intervention, {objective and subjective criteria}, clinical best practice knowledge and collaboration with the patient, physician and multidisciplinary treatment team to pace care, achieve quality outcomes and negotiate appropriate reimbursement. Ensures the timely and seamless clinical transition of patients through medically appropriate levels of care.

Role Responsibilities:
MISSION AND VALUES: Be a visible model for the hospital's mission and values. Exhibit the values and philosophy of SSM Health Care and St. Marys Hospital Medical Center in daily activities and perform job functions in accordance with hospital policies. Respect the privacy and dignity of individuals, courteously provide them with services and information and recognize the patient care mission of the hospital, its spiritual heritage, and its overall philosophy.
CLINICAL: Reviews, on admission, all patients identified for review to determine the medical necessity and appropriateness of admission using approved criteria and standards. Assess all assigned patients in person and integrates family information from Social Work to collaboratively determine potential and actual risks to recovery, and the next level of care needed. Completes and documents all phases of utilization review, including Day One Assessments an Concurrent Reviews, avoidable day reporting, and negotiate reimbursement with payers and/or other arrangements and access to necessary care. Accountable for coordinating the implementation of the Discharge Plan, including documentation in the medical record. Holds, interprets, and integrates the patient’s story into the overall multidisciplinary plan of care. Coordinates/facilitates access to services and patient care progression using best practice interventions that will produce favorable patient outcomes within a target LOS. Collaborates with physicians, nursing, social work, and multiple disciplines, departments, payers, and agencies to eliminate barriers to efficient delivery of care in the appropriate setting. Refers cases as necessary to Vice President of Medical Affairs or Physician Advisor when significant utilization or quality issues are identified. Leads or co-leads Care Coordination rounds per policy and refers patients for Complex Care Rounds. Collects and records all information and data needed for review and reporting purposes utilizing available computer systems. Actively participates in clinical performance improvement activities as assigned. Maintains liaison with outside review entities to assure ongoing certification of patient stays necessary to guarantee hospital reimbursement from third party payers. Builds a network of positive working relationships that advocate for the patient. Documents clinical activity in the medical record and supports and coaches accurate clinical documentation by physicians and others. Completes whatever paperwork is necessary to facilitate the patient’s transition through levels of care. Initiates and assists in Medicare Hospital Initiated Notices of Noncoverage (HINN).
CUSTOMER RELATIONS: Consistent with the hospital vision to surpass the expectations of those who depend on us, demonstrates a customer focus while providing service (e.g., maintain confidentiality, is courteous to all customers- patients, families and all other hospital staff-addresses and follow up on departmental customer concerns). Provide excellent customer services. Know and practice hospital identified customer service behaviors. Identify responsiveness to customer needs as a personal priority.
QUALITY: Support the importance of Continuous Quality Improvement. Participate in department quality improvement projects. Participate in hospital wide interdisciplinary quality improvement projects. Perform clinical data abstraction as needed. Make suggestions for continuous improvement in department procedures and processes.
HUMAN: SELF DEVELOPMENT: Be a self-learner and foster learning in others. Pursue continuing education in area of expertise/leadership. Achieve and maintain hospital wide and department identified competencies. Participate in educational offerings provided by the hospital. Attend all mandatory training programs. DEPARTMENT STAFF MEETINGS/SHARED GOVERNANCE COUNCILS: Actively participate in departmental staff meetings. Participate in shared governance and decision-making. POLICIES AND PROCEDURES: Comply with hospital and department policies and procedures. Comply with all quality and regulatory standards. RECOGNITION & SUPPORT: Recognize, value, and build on differences and commonalties in people. Recognize, acknowledge and support the contributions of all co-workers. OTHER: Participate in education and training of new department employees and students as needed. Provide on-call and scheduled coverage for weekends. Participate in hospital wide orientation process specific to departmental role. Maintain work area in a clean and orderly manner. Perform other duties as requested.
TEAM WORK: Exhibit an approachable, interactive style in relationships. Recognize and value contributions of coworkers. Use team process and consensus building for decision-making. Act with integrity and honesty, being willing to trust others and able to engender trust.
PLANNING: Projects, department activities and programs are based on the SSMHC/WI strategic plan. Participate in identifying new department opportunities that contribute to the strategic plan and departmental goals. Participate in the department process for accomplishing and measuring outcomes.
FISCAL: Effectively manages work hours to stay within budgeted FTE hours.


Minimum Qualifications:
Associate Degree in Nursing
Registered Nursewith the State of WI
Two to three years of experience as a nurse, preferably in an acute care setting.
Must be skilled in nursing theory and able to utilize nursing practice skills.
Sufficient medical knowledge to effectively evaluate medical records.
Must be skilled in establishing and maintaining effective interpersonal relationships with patients of all ages.
Must be skilled in linking patients and families to appropriate resources.
Must be able to communicate well, both verbally and in writing.
Must have the ability to work collaboratively with the medical staff and peers.
Must be organized and able to work independently.

Preferred Qualifications:
Bachelor Degree in Nursing
Previous case management experience
St. Mary's is a 440-bed tertiary referral hospital offering inpatient practice residency program. Since 1912, St. Mary's has provided service and outpatient treatment and diagnostic services in primary care and nearly all specialties. Medical/surgical areas of special focus include the Family Birth Center, pediatrics, Neuroscience Center, geriatrics, orthopedics, emergency services and more. St. Mary's is affiliated with the University of Wisconsin School of Medicine's three-year family to much of south-central Wisconsin including Dane County and 17 other nearby counties. In the growing city of Sun Prairie, northeast of Madison, St. Mary's Emergency Clinic provides services to more than 30,000 residents.
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