RN Case Manager

Role Overview

• Conduct initial intake calls as well as scheduled and urgent patient outreach based on individual patient’s needs and risk levels to review and update the care plan, monitor progress, ensure needs are met, and identify new areas of concern
• Provide ongoing care coordination for an assigned panel of complex patients
• Conduct needs assessments and develop plans of care in partnership with the rest of the patient’s care team
• Ensure care is coordinated, patient-centered, and aligned with the needs and wishes of the patient
• Support patients during care transitions, including outreach and assessment during and post hospitalization to ensure discharge needs are addressed, to facilitate provider follow-up, and to perform medication reconciliation
• Identify and implement interventions and collaborate closely with ConcertoCare’s multidisciplinary team (providers, Director of Clinical Care, social work, behavioral health, and clinical pharmacy), external providers, and social service organizations to: (1) address gaps in care, (2) mitigate the risk of inpatient admissions, readmissions, emergency room visits and movement to an institutional setting, (3) and keep patients safely living in their desired and appropriate home environment
• Identify and verify appropriate utilization of resources across the continuum of care
• Actively participate in interdisciplinary care team huddles, and other clinical meetings
• Participate in quality improvement and evaluation processes
• Adhere to compliance policies, procedures, and standards of conduct including all applicable laws and regulations
• Serve as a mentor for new hires and existing case management team members
• Other duties as assigned.

Requirements

• Current RN License in good standing in the state of practice required or an unencumbered multistate license
• Bachelor's degree in nursing required, or associates in nursing with other clinical or business bachelor’s degree
• Minimum of 4 years experience working in a clinical setting, with at least 2 years of case management experience in home health care, ambulatory care, community public health, and/or the insurance setting
• Certified Case Manager (CCM) certification or commitment to complete when eligible
• Geriatric care experience is highly desired
• 2 years of discharge planning, utilization management, case management, performance improvement, and/or managed care preferred
• Knowledge of Medicare and Medicaid regulations and insurance benefits preferred
• Strong knowledge of clinical best practices as they relate to case management, discharge planning, utilization management, performance improvement, and/or managed care
• Strong clinical skills and ability to implement evidence-based care
• Ability to manage patient complexity and multiple clients with diverse needs
• Demonstrated ability to triage patient-reported symptoms and issues that require escalation to our field-based team and to apply critical thinking skills in unexpected circumstances
• Ability to communicate effectively in writing and verbally
• Demonstrated ability to perform multiple concurrent tasks with minimal supervision and meet deadlines
• Ability to work in a fast-paced, dynamic environment and work well with others on a team
• Proficient computer skills including Microsoft Office Suite (Outlook, Excel, PowerPoint, Word) as well as clinical systems/ EMR competency
• Knowledge and ability to navigate internet-based tools and applications, and proficiency in computer documentation
• Demonstrates a high level of professionalism.

Benefits

• Yearly continuing education allowance
• Medical, Dental, Vision and 401k
• Competitive salary and bonus program
• 15 days of PTO
• 8 paid holidays yearly
• 3 floating holidays