CARE MANAGEMENT SPECIALIST RN

Overview

The Care Management Specialist RN is passionate about advocating for patients' needs and helping them navigate the healthcare system and engages with assigned patient population in the primary care setting to promote optimal health and deliver direct nursing care in accordance with established policies, procedures and protocols of the healthcare organization. This position will lead care management / coordination for medically complex children and adults and act as a resource, and guides families and patients through disease self-management, and serves in an expanded health care role collaborating with inpatient care management specialists, Care Connect team, patients and families to ensure delivery of quality, efficient, and cost-effective health care.

The Care Management Specialist RN demonstrates excellent customer service performance in attitude and actions that are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant Healthcare and the commitment to Extraordinary Care for Every Generation.

Responsibilities

• Coordinates patient care through ongoing collaboration with PCP, patient / family, community, and other members of the health care team.
• When appropriate, takes the lead in ensuring continuity of care extends beyond the practice boundaries. Continually monitors patient / family response to plan of care and revises the care plan as indicated.
• Addresses and refers for social determinants of care needs, i.e. access to health care, educational, and psychosocial needs of the patient / family.
• Actively manages a caseload of approximately 85 to 120 patients.
• Fosters a team approach and includes patient / family as active members of the team.
• Serves as liaison to acute care hospitals, specialists, and post-acute care services.
• Responsible for developing a comprehensive individualized plan of care to promote overall health and wellbeing. Continually monitors patient / family response to plan of care and revises the care plan as indicated.
• Identify high-risk patients and use standardized assessment tools such as depression screenings, functionality and health risk assessments.
• Provides patient self-management support with a focus on empowering the patient / family to build capacity for self- care.
• Maintains required documentation for all Care Management activities including patient progress and treatment recommendations in EMR that can be shared with treating providers and codes appropriately for services provided. Track patients follow up and clinical outcomes using a registry, within EMR or spreadsheet.
• Responsible for transition of care (TOC) calls, within 2 business days of discharge, from an acute or semi-acute setting to home. TOC includes medication reconciliation, ensuring PCP or specialist follow-up appointments are arranged, assessing symptoms, teaching warning signs, reviewing discharge instructions, coordination of care, and problem-solving barriers.
• May be responsible for covering multiple offices.
• Participate in required continuing education opportunities.

Qualifications

EDUCATION / EXPERIENCE REQUIREMENTS :

KNOWLEDGE / SKILLS / ABILITIES :

WORKING CONDITIONS / PHYSICAL DEMANDS :

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