Nurse Care Manager, Clinical Operations - Bend, Oregon

Overview

About Our Company

We’re a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care.

Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes and virtually through Village

MD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians.

When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care.

Please Note: We will only contact candidates regarding your applications from one of the following domains: , , , , , , or

Position Summary:

The RN Care Manager will participate in a dynamic interdisciplinary team to provide case management services to identified complex, high-risk patients across the care continuum. The Care Manager will partner with patients and families by engaging them in the accountability of care in order to improve patient experience. The Care Manager will achieve goals of lowering costs and improving clinical outcomes by serving as an integral primary care team member, managing assigned populations of patients, and coordinating care for patients identified with potential avoidable utilization, gaps in care, and/or at-risk status.

Responsibilities may include development of care plans, collaboration with external agencies, case conferences, self-management support and health coaching.

Essential Job functions:

• Works with multidisciplinary transitional care team to facilitate seamless patient transitions across the continuum of care.
• Assesses assigned population of patients. Independently prioritizes care management needs (high need, high-risk and/or high cost).
• Applies case management concepts, principles and strategies to assist the high-risk patient in achievement of prevention and treatment goals.
• Care plan development and monitoring for the highest need/highest cost patients in collaboration with the Primary Care Physician.
• Documents appropriately in the electronic health record, care management registry and any required patient tracking documents. Employs appropriate and timely use of tasking in the EHR. Reviews and updates medication and problem lists.
• Performs all care management activities across the continuum of care while adhering to the core values of patient confidentiality, privacy, safety, advocacy, and adhering to ethical, legal, and accreditation/regulatory standards.
• Delivers care management services within the scope of licensure in accordance with SMG policy.
• Assumes accountability for the quality of care.
• Continually seeks new knowledge and learning regarding comprehensive primary care and chronic disease management.
• Other duties as assigned.

General

Job functions:

• Ensures that all assigned “Hospital Discharge” and “Rehab Discharge” tasks in the EHR are addressed in a timely manner, identifying whether the patient requires follow up with primary care or a specialty department at SMG.
• Performs telephonic outreach to patients within 2 business days of discharge.
• Documents all the elements for transitional care management in an Encounter in the EHR.
• Ensures that the Transitions of Care note is sent to the appropriate PCP for review and signature in the EHR.
• Schedules follow-up appointment(s) for patients in EMR. High complexity patients are scheduled within 7 calendar days post discharge. Moderate complexity patients are scheduled within 14 calendar days post discharge.
• Follows the patients’ status for 30 days, updating the Primary Care Physician and communicating with family members as needed. Ensures outreach to patient post discharge day #30 to confirm that patient has not been readmitted.
• Provides continued intense care management to the highest risk patients beyond the 30-day period as clinically warranted.

• High-Risk…