Outpatient Care Manager Star Community Health Registered Nurse

About the position St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. The Outpatient Care Manager, Registered Nurse, is responsible for providing care management services to outpatients and their families as directed by the policies and procedures of the entity and Outpatient Care Management Department. The OP CM RN provides professionally established methods of assessing a patient's status of chronic and acute illnesses and assists patients and families in resolving problem areas and connects them with other members of the care team with a goal of assisting patients with self-management. Responsible for the medical complexity of patient care as it relates to medical stability and wellness, the OP CM RN collaborates with both health care and community partners to address and promote self-management of care needs. The OP CM RN also collaborates with the Outpatient Care Manager SW, and other members of the Care Management team as needed to address the social needs of the medically complex patient. The OP CM RN works on a hybrid schedule and may need to see patients in an office setting as needed.

Responsibilities

• Provides assessment, care planning and intervention to patients and caregivers, including care planning, advocacy, as well as clinical intervention as appropriate.
• Follows the care management process including patient identification, engagement/enrollment, assessment, care planning, and case closure.
• Manages a caseload of patients and prioritizes new referrals with patients who require follow up to complete care plan goals.
• Appropriately refers to other care manager disciplines within the department to meet the patient's holistic health care needs.
• Appropriately delegates tasks to the Care Manager Outreach Coordinator (CMOC) as needed.
• Practices motivational interviewing skills and teach-back skills when interviewing/assessment of patients.
• Consults with providers, nurses, and other members of the health care team to facilitate interdisciplinary care and address effective continuum of care coordination.
• Maintains awareness of insurance benefits as well as community resources to provide and facilitate appropriate referrals based on patient/caregiver agreement.
• Organizes individual patient care meetings with internal and as necessary, external multidisciplinary team members and the patient/caregiver to evaluate progress and to identify and resolve problems that may interfere with a positive patient outcome.
• Ensures accurate clinical and patient care documentation in patient charts, completes reports and other requested/required patient documentation as needed, and maintains required statistical documentation for the department's management information system.
• Demonstrates competency in the assessment, range of treatment, knowledge of growth and development, and communication appropriate to the age of the patient treated.
• Participates in quality and/or performance improvement projects/pilots.
• Participates in orientation of new Care Management staff as assigned.
• Facilitates follow-up primary care visits within 48 hours of ED visit, urgent care appointment, or hospital discharge.
• Responsible for working with the patient and patient care team to develop an individualized treatment care plan – including follow-up appointments, labs and other care coordination.
• Tracks follow-up visits with appropriate specialists for complex patients.
• Communicates with and coaches’ patients to ensure that they are aware of discharge instructions; have necessary prescriptions; have access to medications and understand how to take the necessary medications, including what to look for regarding adverse events as per their care givers’ instructions.
• Facilitates the information flow between hospitals, long-term care facilities, home health representatives, and the patient’ s primary care team.
• Works with providers, clinical staff members, and clerical staff members to help identify high risk, high need patients.
• Assists physicians and other care team members in implementing processes for best practices in preventive services, chronic care and disease management.
• Utilizes electronic health record, chronic disease registry, and other quality reporting software to capably manage the care of individual patients and populations.
• Works collaboratively with providers and the care team to ensure patient adherence to medical plan of care, including all appropriate preventive and disease-specific screenings, interventions, and treatment goals – including self-management goals.
• Identifies, utilizes, and properly directs patients to cultural and community resources.
• Verifies that practices have necessary behavioral health screening tools.
• Compliant with annual network or department competencies focusing on health coaching patients on self-management tools related to chronic illnesses and appropriate health coaching.
• Maintain timely, accurate, complete, and consistent documentation appropriate to role in the electronic medical record.
• Maintains expertise in telehealth procedures, participates in staff meetings, participates in network and/or department committees or special projects as assigned.
• Participates in peer educational presentations.
• Supports Network and department goals and objectives.
• Demonstrates financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes, and practices.
• Complies with Network and departmental policies regarding attendance and dress code.

Requirements

• RN degree and license for the appropriate state (PA & NJ) required.
• 3+ years of direct patient care experience.
• Proficient in Epic Clinical EMR, Window applications preferred.

Nice-to-haves

• BSN preferred.
• Prior care management experience preferred.

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