The R.N. Care Manager, as a member of the health care team, is imbedded in the Primary Care Practice. The role collaborates to enhance the delivery of patient care services along the continuum of care. The Care Manager meets patient's needs efficiently and expeditiously by continuously improving the patient's experience, helping to ensure the institutional standards of high quality patient care, reducing cost, and ensuring reimbursement. Through broad knowledge of clinical care and systems management, the Care Manager evaluates, predicts, and facilitates the trajectory of patient care. The model has a Care Manager panel ratio of approximately 1:200 patients. The care is supported by a team that includes Social Workers, Pharmacist, and Community Resource Specialists.
PERFORMANCE REQUIREMENT / DUTIES AND RESPONSIBILITIES:
Performs a comprehensive nursing/psycho-social assessment on a targeted patient population as defined by MGH/MGHPO and contractual constituents.
Identifies key barriers to care and patient's ability to manage their health and wellness through initial and on-going assessments.
Implements a plan of care, appropriately utilizing the menu of services for patients, as well as insurance approved, community, practice-based, and MGH services.
Develops a comprehensive plan of care in conjunction with the patient's PCP.
Ensures that all elements critical to the plan and trajectory of care have been communicated to the patient/family and members of the Interdisciplinary Team.
Assesses patient/family continuing care needs in collaboration with the interdisciplinary team in the review/revision of the therapeutic plan to expedite and arrange non-acute care.
Monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, friendly, high quality, efficient, & cost effective.
Monitors patients in Non-Acute facilities in collaboration with the iCMP Care Team.
Documents in the medical record as appropriate, as part of the Interdisciplinary Team.
Identifies patients/families with complex psychosocial and non-medical discharge planning issues; refers to iCMP team, as appropriate.
In collaboration with iCMP team, monitors the patient's progress and plan of care with the aid of internal and external unitization and quality guidelines. Identifies, documents, and reports issues and system barriers.
Complies with Care Management Standards of Practice, based on assignment.
Evaluates, coordinates, manages, and documents all activities related to clinical approval/denial processes and communicates relevant information to patients/families, members of the Interdisciplinary Team, hospital departments, and payers.
Participates in On Call coverage per department guidelines.
Performs other duties as assigned.
Ensures timely implementation of the plan of care.
Collects data as designed by the projects for ongoing analysis.
Participates in practice-based Medical Management meetings, as appropriate.
Able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served on his/her assigned unit. (i.e. Pediatric, Medical/Surgical, PCP, ED, Admitting)
• RN with current license to practice in Massachusetts required
• CM certificate desirable.
• Minimum of 5 years experience in a medical/surgical setting required, three of which must be related.
• Acute hospital experience preferred.
• Related care management experience preferred.
Martha's Vineyard Hospital and Windemere Nursing & Rehabilitation Center are Equal Opportunity Employers. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law.
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