OVERVIEW OF POSITION:
Responsible for ensuring the continuity of care in both the inpatient and outpatient setting utilizing the appropriate resources within the parameters of established contracts and patients’ health plan benefits. Facilitates continuum of patients’ care utilizing advanced nursing knowledge, experience and skills to ensure appropriate utilization of resources and patient quality outcomes. Performs care management functions on-site or telephonically as the need arises. Works in conjunction with the care team and PCP as care team leader. Ensures evaluation is in alignment with site based goals.
Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
Prioritizes patient care needs upon initial visit and addresses emerging issues.
Meets with patients, patients’ family and caregivers as needed to discuss care and treatment plan.
Identifies and assists with the follow-up of high-risk patients in acute care settings, skilled nursing facilities, custodial and ambulatory settings.
Consults with physician and other team members to ensure that care plan is successfully implemented.
Coordinates treatment plans with the care team and triages interventions appropriate to the skill set of the team members.
Uses protocols and pathways in line with established disease management and care management programs and approved by medical management in order to optimize clinical outcomes.
Monitors and coaches patients using techniques of motivational interviewing and behavioral change to maximize self-management.
Oversees provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc., in order to maintain continuity of care.
Works in coordination with the care team and demonstrates accountability with patient management and outcome.
Discusses Durable Power of Attorney (DPoA) and advanced directive status with PCP when applicable.
Maintains effective communication with the physicians, hospitalists, extended care facilities, patients and families.
Provides accurate information to patients and families regarding HMO benefits, community resources, referrals and other related issues.
Participates actively in assigned Care Management Coordination Committee (CMCC) meetings.
Documents pertinent patient information and Care Management Plan in Electronic Health Record and Care Management Systems as appropriate.
Coordinates care with central departments on assigned patient caseload, including out-of-area, inpatient central and transplant.
Demonstrates a thorough understanding of the cost consequences resulting from Care Management decisions through utilization of reports and systems such as Health Plan Benefits, Division of Financial Responsibility (DOFR), utilization of metrics and CM reports.
Adheres to departmental policies and procedures as approved by Office of the Medical Director (OMD) Quality Committee.
Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Performs additional duties as assigned.
Bachelor’s degree from a four-year college and/or a professional certification requiring formal education beyond a two-year college.
Graduation from an accredited school of Nursing.
California RN license.
Bachelor’s degree in Nursing preferred.
Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross).
Over 3 years and up to and including 5 years of experience in clinical setting demonstrating the ability to assess, document and implement the nursing care plan.
Past clinical experience.
3 to 5 years of acute nursing experience in critical care.
Previous care management, utilization review or discharge planning experience.
KNOWLEDGE, SKILLS, ABILITIES:
Ability to type 25 wpm.
Knowledge of current standards of patient care.
Thorough understanding of RN scope of practice.
Manual dexterity to use/handle equipment and instruments.
Ability to effectively communicate and collaborate with physicians, patients, families and ancillary staff.
Ability to make sound, independent judgments and act professionally under pressure.
Valid California driver’s license, insurance and vehicle for work-related travel.
PHYSICAL REQUIREMENTS IN ACCORDANCE WITH ADA:
Carrying/Lifting: Occasional / 0-25 lbs
Standing: Frequent / Up to 6 hours per day
Sitting: Frequent / Up to 6 hours per day
Walking: Frequent / Up to 6 hours per day
Repetitive Motion: Keyboard activity, telephone use, writing, reaching, grasping, pushing, pulling
Visual Acuity: Ability to view computer monitor and read newsprint with or without corrective lenses
Environmental Exposure: Exposure to biohazard materials (human blood and fluid, communicable diseases, chemicals such as gluteraldehydes and other germicidal agents)