Care Management

Premier Health - Moraine, OH3.4

Full-timeEstimated: $48,000 - $68,000 a year
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Position information

Title: Care Manager, RN

Facility: Fidelity Health Care

Job Reports to: Manager, Pam Henry

Premier Health Mission, Vision, and Values

The Premier Health Mission

We will build healthier communities with others who share our commitment to provide high-quality, cost-competitive health care services.

The Premier Health Vision

Patients, physicians, and employees will choose Premier Health over any other health care provider in Southwestern Ohio. We will earn their choice, and grow our market leadership by anticipating their needs and exceeding their expectations.

§ Patients and their families will choose us for our quality outcomes and compassionate care at a competitive price.

§ Physicians will choose us as collaborative partners for our easy, efficient practice environment and with a shared passion for high-quality medical outcomes.

§ Our employees will choose us as a great place to work, learn and build a career.

The Premier Health Values

§ RESPECT each person’s dignity.

§ Act with INTEGRITY to do the right thing in all aspects of our responsibilities.

§ Serve with COMPASSION that embraces each individual’s concerns and hopes.

§ Commit to EXCELLENCE as measured to the highest level of performance.

Position Summary

General Summary/Responsibilities:
The RN Care Manager will provide a systematic organization of care with the Physician Practice and will coordinate with other care team members and/or settings. The RN Care Manager will provide high quality, patient centered care management to patients identified as needed by high-risk registries. This will include, but is not limited to developing individualized care plans, care coordination across the continuum, prevention plans, and ongoing monitoring.

Dimensions:
Care Management results from a complex exercise of clinical judgement, occurs through a relationship-based engagement with the care team, and addresses the patient’s identified health care goals. Essential functions include:

Documentation of a mutually agreed upon plan of care based on patient’s goals, addressing all significant ongoing health problems and risks.
Provide ongoing assessment, monitoring, and tracking in E H R. Care will be managed by the use of a registry functionality with interventions triggered by regular review and monitoring.
Provide proactive care and education outside the routine office visit, for example by phone, Patient Portal, or other access activities.
Build a trusting, professional relationship with the patient, family, and/or caregivers.
Utilize self-management and shared decision-making tools.

Scope/Span of Control: N/A

Supervisory Responsibilities (if applicable)

Supervises FTEs: No

Number of FTEs Supervised: N/A

Exercises full management authority including performance reviews, discipline, termination and personnel hiring No

Fiscal Responsibilities (if applicable)

Annual Revenue in Dollars: N/A

Annual Expense in Dollars: N/A

Financial Accountability: N/A

Population Served

Age of Population Served - Choose all that apply

Infant (birth – less than 1 year)

Pediatric/Adolescent (1 – less than 18 years)

Adult (18 – 64 years)

Geriatric (65 years & older)

All Age Groups (Birth & Above)

Not Applicable

Qualifications

Education

Minimum Level of Education Required: Bachelor's degree

Additional requirements:
§ Type of degree: Bachelor’s

§ Area of study or major: Nursing

§ Preferred educational qualifications: Bachelor’s

§ Position specific testing requirement: N/A

Licensure/Certification/Registration

§ Current Ohio RN Licensure within the state of Ohio

Experience

Minimum Level of Experience Required: 1 - 3 years of job-related experience

Prior job title or occupational experience: N/A

Prior specific functional responsibilities: Demonstrate accurate and timely data and computer skills

Preferred experience: EPIC knowledge

Other experience requirements: Solid knowledge of chronic conditions, strong assessment, and patient interview skills

Knowledge/Skills

1) Work closely with all clinical care teams and serve as a resource in Care Management.

2) Ensure safe and effective care while patient transitions through care continuum.

3) Serve as a liaison between consulting Physicians, APPs, hospitals, ER, and other healthcare resources, as well as the patient and family.

4) Collaborate with other Care Managers and LISWs to identify care transition services/needs.

5) Prioritize referrals and activities according to pathways/protocols.

6) Serve as a lead to assist patients setting SMART goals for self-management of their health conditions.

7) Maintain accurate and timely documentation in a confidential and compliant method.

8) Participate in measuring clinical outcomes, analysis activities, and performance improvement.

9) Utilize registries and serve in the role of population management by reaching out to patients when identified.

10) Educate, encourage, and engage patients in their care through motivation, coaching, and active listening techniques.

11) Serve as a resource for care coordination and pre-visit planning. Anticipate the needs of the patient population, overseeing process and completion.

12) Serves as the primary contact for quality goals for the patient within the office.

13) Maintain strict confidentiality and follow HIPAA guidelines.

14) Treat patients and families with dignity and respect.

15) Will be actively involved in managing chronic conditions, prevention, and cost-effective initiatives.

16) Assess, document, and communicate barriers when patient is unable to meet treatment goals.

17) Use customer friendly, professional communication at all times.

18) Utilize consistent documentation throughout EPIC system, following identified process.

19) Perform other related work as required.

Physical Requirements & Working Conditions

Physical Requirements:
Pulling

2 - Occasionally (11% - 40%)

Standing

3 - Frequently (41% - 75%)

Other sounds

1 - Rarely (0% - 10%)

Twisting

2 - Occasionally (11% - 40%)

Reaching

2 - Occasionally (11% - 40%)

Visual Acuity Near

3 - Frequently (41% - 75%)

Walking

3 - Frequently (41% - 75%)

Manual Dexterity

3 - Frequently (41% - 75%)

Visual Acuity Far

2 - Occasionally (11% - 40%)

Sitting

2 - Occasionally (11% - 40%)

Use both hands

3 - Frequently (41% - 75%)

Vision Color

2 - Occasionally (11% - 40%)

Pushing

2 - Occasionally (11% - 40%)

Talking

3 - Frequently (41% - 75%)

Concentrating

3 - Frequently (41% - 75%)

Climbing

2 - Occasionally (11% - 40%)

Lifting <10 pounds

2 - Occasionally (11% - 40%)

Interpersonal Skills

4 - Consistently (76% - 100%)

Stooping

2 - Occasionally (11% - 40%)

Lifting >10 pounds

2 - Occasionally (11% - 40%)

Reading

4 - Consistently (76% - 100%)

Kneeling

2 - Occasionally (11% - 40%)

Normal hearing both ears

3 - Frequently (41% - 75%)

Thinking

4 - Consistently (76% - 100%)

Working Conditions:
1. General office environment.

2. Climate controlled environment.

3. May work some evenings and weekend hours to complete projects or meet the needs of the department.

4. May be required to work overtime as defined by the needs of the department.

Organizational Standards

§ Maintains and supports overall philosophy, goals and objectives of Fidelity Health Care and the Independent Care Program and its contracts.

§ Demonstrates ability to follow nursing process:
o Provides thorough physical, mental and social assessments to individuals during each home care visit.

o Develops plan of care in coordination with patient, family members, physician and Independent Care team.

o Implements home care services according to plan of care.

o Observes and monitors the clinical and psychosocial status of the patient on an ongoing basis with appropriate intervention.

§ Complies with all agency regulations/policies/procedures:
o Submits all documentation timely per policy and contract mandates.

o Implements home care services according to plan of care.

o Follows agency and governing bodies' standards of practice.

o Follows and maintains contractual obligations, as directed.

§ Demonstrates effective case management skills:
o Communicates all pertinent clinical and psychosocial information to supervisor and/or Independent Care team members as indicated.

o Demonstrates knowledge and utilization of community health nursing and community resources.

o Provides patient/family teaching regarding disease process and prevention, infection control, home safety, medications and side effects, and day-to-day management of the patient in the home setting.

§ Attends all scheduled in-services and staff meetings.

§ Strives to maintain/improve home care and clinical education.

§ Performs case workload review as designated by the supervisor.

§ Appropriately arranges time off coverage and communicates this with agency.

§ Participates in on-call coverage of the agency. Is responsible for maintaining minimum weekend on-call, holiday or other requirements established by the department.

§ Maintains minimum productivity expectations.

§ If you are a member of a specialty service, your primary accountability for case acceptance is with that specialty.

§ You are required to maintain a consistent caseload within that specialty service per pay period.

Essential Duties & Functions

Essential Duties & Functions:
The RN Care Manager will take a lead role in assuring the care team is informed of the overall care plan, progress and needs.

Other Duties & Functions:
As assigned

The above duties and responsibilities may be essential job functions subject to reasonable accommodations. All job requirements listed include the minimum knowledge, skills, and/or ability deemed necessary to perform the job proficiently. This job description is not to be constructed as an exhausted statement of duties, responsibilities, and requirements. Employees may be required to perform any other job-related instructions as requested by their supervisor, subject to reasonable accommodations.