Care Mgr, Contg Care Network

Job Description

Description

Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.

Summary:
The purpose of the this position is to establish, implement, monitor, and evaluate high quality, cost effective plans of care for patients receiving care within a continuing care facility or agency (home health, skilled nursing facilities, assisted living facilities, etc.). The care manager will work effectively with facility/agency teams on behalf of UNC Health Care. The overall goal of the position is to manage the care of patients by developing expected patient outcomes, defining appropriate resource utilization while promoting cost effective continuity of care. The care manager will develop collaborative relationships with facilities and agencies; and other interdisciplinary team members including but not limited to providers, care managers, social workers, nursing and therapists to foster high quality, efficient care delivery. The care manager will engage patients and their families by providing objective information and support throughout the continuing care episode. The Care Manager must be highly organized professional with great attention to detail, adaptable to frequent change, and compliant with regulatory and departmental guidelines and policies.

Responsibilities:

1. Care Management: Ensure a seamless, coordinated and safe transition into continuing care setting including but not limited to medication reconciliation, implementation of care orders and recommendations. Establishes functional improvement goals for discharge with patient and family in collaboration with care providers in the continuing care setting. Facilitates patient education and engagement aligned with discharge goals. Follows, monitors and troubleshoot when needed the patient’s plan of care in continuing care setting, recommending necessary changes to the plan to ensure well-being and desired outcomes. Tailors continuing care experience to an established set of functional goals established at the initiation of continuing care. Manages patients stay in the continuing care setting(5)Participates in patient care conferences as appropriate within the continuing care setting 

2. Case Identification and Prioritization: Review all discharges to continuing care services on daily basis. Identifies specific patient populations for care management. Reviews patient documentation and plan of care in EpicTM. 

3. Consultation: Consults with hospital based or population health care management, care providers and/or other members of the health care team as needed to discuss expectations for continuing care. Consults with patient and their family. Serves as a resource contact to patients, families, providers and other members of the health care team. 

4. Care Progression and Transition Planning: Ensures handoff of high-risk patients to population health care management or acute care management to ensure safe transition from continuing care. Ensures planning and safe transition of care from continuing care setting. Actively participates in meetings (with CC setting and/or health care system) to provide and receive information on patient’s progression. Promotes timely discharge and transition to home or other appropriate setting. Escalates concerns (clinical or operational) to medical and network leadership. 

5. Documentation: Documents activities, events, communications and information in EpicTM in a timely, accurate and complete manner. Identifies and documents events that could cause a delay in discharge from continuing care. 

6. Compliance and Quality/Performance Improvement: Collects data through patient tracking to facilitate patient outcome data collection and analysis. Participates in meetings with faculties/agencies in reviewing clinical, quality and operational outcomes as appropriate. Identifies practice and/or program improvement opportunities to assist with delivery of high quality cost effective care. Collaborates with other members of the continuing care network, health alliance and care management to develop and implement programs to meet goals and specific needs of populations. Maintains knowledge and complies with regulatory and third party payers’ procedures/requirements and documentation. 

7. Professionalism/Leadership: Demonstrates flexibility and professionalism in a dynamic environment with various priorities and assignments. Uses critical thinking skills to evaluate and prioritize changing demands in work. Collaborates with other health care team members – internal and external- to accomplish goals and mission. Represents Continuing Care Services and UNC Health in a professional manner at all times. Maintains current knowledge of institutional and departmental expectations for job performance through attendance at meetings, review of communications, departmental documents and independent review of institutional and departmental policies and guidelines as needed. May assist with training, education and/or precepting as needed. 

8. Confidentiality: Uses established policies and processes to handle, discuss and transmit protected health information in a manner consistent with privacy and compliance expectations and policies. Remains aware and vigilant of environment when handling and discussing protected health information.

 Other Information 

Other information:

 Education Requirements: ● Graduation from a state-accredited school of professional nursing with a Bachelor’s degree in Nursing Licensure/Certification Requirements: ● Licensed to practice as a Registered Nurse in the state of North Carolina ·NC driver’s license and vehicle insurance 

Professional Experience Requirements: ● Three years of broad clinical experience in the acute care or continuing care environment caring for patients with complex medical conditions

 Knowledge/Skills/and Abilities Requirements: ● Requires critical thinking, decisive judgement, multi-tasking and ability to work independently with minimal supervision• Working knowledge of CMS criteria for SNF, Rehab, Home Health and Hospice •Strong interpersonal skills and ability to work collaboratively with patients, network staff and internal care providers• Experience with clinical pathways, data analysis and health care operations •Ability to analyze and present data accurately and effectively •Outcome focused with the ability to manage competing demands• Strong communication skills, both written and verbal •NC driver’s license and vehicle for travel to continuing care network facilities and agencies