RN Outpatient Care Manager

Complex/Catastrophic Patient Manager

This job manages identified complex/catastrophic patients attributed to the organization and its Network of partner providers. Uses the case management process to assess the healthcare needs of the enrollee, identify barriers to care, develop a comprehensive treatment plan complete with specific goals and objectives, implement a treatment plan in collaboration with the PCP team and the other providers involved in the patients' care, negotiate and coordinate service for the patient, monitor and evaluate the effectiveness of the plan in achieving the goals and objectives, and change and modify the plan as needs and situations change. This job is an integral part of the multi-disciplinary care team and as such coordinated care among multiple healthcare providers, the patient's caregiver(s), community services, payors, and others involved in the care of the patient to ensure services are provided seamlessly throughout the continuum of care. Arranges and coordinates resources necessary to manage the patient's disease processes in the home environment. This job adheres to the CMSA Standards of Practice for Care Management.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties. This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at the company's discretion.

Education

Required - Graduate of an accredited school of nursing.

Preferred - Bachelor's degree in nursing.

Work Experience

Required - 3 years of experience in a clinical setting; experience documenting in an electronic medical record and using Microsoft Office; experience working in a multi-disciplinary team environment.

Preferred - Experience in case management, care coordination or disease management.

Certifications

Required - Current Registered Nurse (RN) License in the state of practice.

Preferred - Certification as a Case Manager (CCM).

Knowledge Skills and Abilities (KSAs)

• Proficiency in using computers, software, and web-based applications.
• Effective verbal and written communication skills and ability to present information clearly and professionally to varying levels of individuals.
• Excellent knowledge of managed care, CMS, Medicaid and other regulatory standards/requirements and ability to use community resources and other resources to facilitate the patient's care throughout the care continuum.
• Good organizational and time management skills and ability to be self-directed and demonstrate good judgement.

Job Duties

• Collaborates with members of the health care team, the patient, and patient's caregiver(s) to develop and implement a coordinated treatment plan across the continuum
• Assesses patient for social determinants of health that may create barriers to care and/or adversely impact the care and treatment plans. Includes SDOH in the care/treatment plan and refers to Social Work or Community Health Worker as appropriate and guided by workflow/process
• Uses the case management process to develop comprehensive cost-effective plans of care for patients in care management
• Collaborates with the multidisciplinary team, Primary Care Provider, and other appropriate care providers to facilitate appropriate care and treatment of the patient
• Coordinates referrals and appointments with members of the care team
• Provides in-depth disease-based patient education and formulates collaborative action plans with patient/caregiver to achieve agreed-upon goals for self-management and to improve patient health status
• Provides community resources to patient, families and/or caregivers to avoid or reduce hospital admission through telephonic and face-to-face contact
• Identifies quality issues that may adversely affect patient outcomes and submit to department leadership
• Performs other related duties as required

The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time. Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards.

This employer maintains and complies with its Compliance & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns. The employer is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Light Work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. NOTE: The constant stress and strain of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is negligible.

Normal routine involves no exposure to blood, body fluid or tissue, but exposure or potential for exposure may occur. The incumbent works with patients who have known or suspected communicable diseases and may enter isolation rooms. There may be an occupational risk for exposure to communicable diseases. Because the incumbent works within a healthcare setting, there may be occupational risk for exposure to hazardous medications or hazardous waste within the environment through receipt, transport, storage, preparation, dispensing, administration, cleaning and/or disposal of contaminated waste. The risk level of exposure may increase depending on the essential job duties of the role.