Full Job Description
St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.
The RN Care Manager (CM) coordinates the overall progression of care, resource utilization, and discharge planning for designated patient populations across the continuum of care. The RN CM works with the providers, social workers and multi-disciplinary care teams to facilitate the achievement of desired patient, quality, and financial outcomes. In general, care managers are assigned to a specific campus. However, all care managers are expected to float to other campuses if the need arises.
JOB DUTIES AND RESPONSIBILITIES:
Assesses the patient’s needs, goals, and barriers in relation to the patient’s clinical condition, psychosocial environment, and socioeconomic resources.
Collaborates with the multidisciplinary team to plan, implement and evaluate the patient’s plan of care through rounding or other methods.
Collaborates with the patient, family or other caregivers, and multidisciplinary team to design a discharge plan respective of the patient’s needs and goals. Re-evaluates and revises discharge plan of care as additional information is obtained or goals change.
Proactively considers options such as palliative care, homecare and other services that work to keep the patient as healthy as possible in the outpatient setting, minimizing the risk of readmissions.
Works as a team with other members of care management, including but not limited to: Social workers, assistants, coordinators, utilization management staff, and director.
Facilitates communication among all treatment team members.
Manages length of stay by proactively identifying and mitigating issues and barriers to care and a successful discharge plan.
Monitors risk assessment using available tools and implements discharge interventions accordingly, minimizing risk of readmission.
Identifies patients with an unplanned readmission and completes root cause analysis.
Collaborates with Outpatient Care Managers to identify patients for handover and post discharge follow up.
Assures compliance with regulatory and payer source requirements.
Issues applicable state/federal regulatory notices as applicable ie.) Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), Bundle Payment Care Initiative (BPCI) notification.
Works closely with the Utilization Management team, including physician advisors to communicate approvals, denials, and change in status to the attending physician and other members of the care team as appropriate.
Actively addresses and monitors resource utilization and documents delays as appropriate.
Arranges for post discharge needs as appropriate, including but not limited to, DME, home care, transportation, prescriptions, and follow up appointments.
Facilitates resolution of issues surrounding patient care in a compassionate manner, utilizing team meetings as appropriate.
Uses electronic systems to accurately document care management functions.
Maintains confidentiality of all protected health information (PHI), St. Luke’s proprietary information, and secures release of information when appropriate.
Complies with Network and departmental policies regarding issues of employee, patient and environmental safety and follows appropriate reporting requirements.
Demonstrates/models the Network’s Service Excellence Standards of Performance in interactions with all customers (internal and external).
Demonstrates Performance Improvement in the following areas as appropriate: Clinical Care/Outcomes, Customer/Service Improvement, Operational System/Process, and Safety.
Demonstrates financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes and practices.
Complies with Network and departmental policies regarding attendance and dress code.
Demonstrates competency in the assessment, range of treatment, knowledge of growth and development and communication appropriate to the age of the patient treated.
Seeks out educational opportunities specific to the role of care management.
Other duties as assigned.
PHYSICIAL AND SENSORY REQUIREMENTS:
Sitting for one to two hours at a time, walk on all surfaces for up to five hours a day, and climb stairs. Must be capable of driving a car and have the ability to finger and handle objects frequently. Occasionally firmly grasp, twist, and turn objects with hands and fingers. May be required to lift, carry, push, and/or pull objects weighing up to 75 pounds. Occasionally stoops, bends, squats, kneels and reaches above shoulder level. Staff must have the ability to hear as it relates to normal conversations and high and low frequencies and to touch as related to telephone and computer keyboard.
POTENTIAL ON-THE-JOB RISKS:
Identified Risks , None Identified and/or Fit Tested Statement Which States That:
Employees who work in patient care areas where they may have potential exposure to patients with suspected or proven tuberculosis (TB) must have the ability to wear a particulate respirator and be fit-tested in compliance with the current recommendations from the CDC (enforced by OSHA) or must provide physician documentation as to the inability to wear a particulate respirator.
SPECIFIC PROTECTIVE EQUIPMENT AVAILABLE: Protective gowns, masks, and gloves are available.
MOST COMPLEX DUTY:
Actively engaging the interdisciplinary team to ensure effective and efficient care coordination.
SUPERVISION (RECEIVED BY AND/OR GIVEN TO):
Supervision received from the clinical coordinator, manager or Regional Director appropriate to the specific campus.
Applies advanced interpersonal, critical thinking, and communication skills in all interactions.
Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!
St. Luke's University Health Network is an Equal Opportunity Employer.