Intensive Community Manager, Complex Care; RN

We’re unique. You should be, too. We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?

We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

• Manages and plans for transitions of care, discharge and post discharge follow-up for patients admitted to key, high-volume/high-priority hospitals.
• Establishes a trusting relationship with patients and their caregivers.
• Collaborates with clinical staff in the development and execution of the plan of care and achievement of goals. Reports variations to PCP/Transitional Care Physicians (TCP) and implements actions as appropriate.
• Builds relationships with preferred acute care providers (hospitalists, specialists, etc.).
• Directs referrals to preferred providers.
• Coordinates the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting. Coordinates the patient care, discharge and home planning processes with hospital case management departments, and other healthcare facilities.
• In conjunction with the PCP, Hospitalist, Medical Director, insurance case manager and the hospital case manager, coordinates the patient transition to the appropriate/least constrictive level of care using a preferred provider.
• Keeps the PCP aware of patient(s) condition via e-mail, DASH, HITS or other appropriate means of communication.
• Introduces self to patient/family and explains Nurse Case Manager’s role and processes to contact the Nurse Case Manager for questions, guidance and education.
• Provides high intensity engagement with patient and family.
• Facilitates patient/family conferences to review treatment goals and optimize resource utilization; provides family education and identifies post-hospital needs.
• Serves as a patient advocate. Enhances a collaborative relationship to maximize the patient/family’s ability to make informed decisions.
• Addresses advanced care planning including treatment goals and advance directives.
• Refers cases to social worker (Hospital and Chen Med/Jen Care/Dedicated) for complex psychosocial and economic needs.
• Refers cases where patient and/or family would benefit from counseling required to complete complex discharge plan to social worker.
• Reports observed or suspected child or adult abuse pursuant to mandated requirements.
• Obtains onsite and EMR access at priority facilities.
• Maintains clinical and progress notes for each patient receiving care and provides progress report to PCP and others as appropriate.
• Submits required documentation in a timely manner and in appropriate computer system.
• Participates in surveys, studies and special projects as assigned.
• Conducts concurrent medical record review using specific indicators and criteria as approved by medical staff. Acts as patient advocate: investigates and reports adverse occurrences, and performs staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery.
• Promotes effective and efficient utilization of clinical resources and mobilizes resources to assist in achieving desired clinical outcomes within specific timeframe.
• Conducts review for appropriate utilization of services from admission through discharge. Evaluates patient satisfaction and quality of care provided.
• Communicates with physicians at regular intervals throughout hospitalization and develops an effective working relationship. Assists physicians to maintain appropriate cost, case and desired patient outcomes.
• Coordinates the provision of social services to patients, families and significant others to enable them to deal with the impact of illness on individual family functioning and to achieve maximum benefits from healthcare services.
• Completes expanded assessment of patients and family needs at time of admission. Completes psychosocial assessment.
• Directs and participates in the development and implementation of patient care policies and protocols to provide advice and guidance in…