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About the Role

Suvida Healthcare is seeking a Nurse Care Manager to provide high-quality care for high-risk patients. This role involves collaborating with a multidisciplinary team to develop strategies for managing complex cases and populations, identifying social determinants of health, managing chronic conditions, and promoting efficient resource utilization. The Nurse Care Manager will implement care pathways, oversee transitions of care, and manage highly complex patients.

Responsibilities

Oversees chronic care and transitions of care management of high-risk patients.
Serves as a resource to the multidisciplinary team for complex patient management, including assessments and care plans.
Performs triage for patients via phone and addresses issues appropriately.
Ensures efficient and organized patient transitions from acute and post-acute settings to home or other transitional care facilities.
Performs comprehensive assessments for physical, mental, and social risk factors, identifying and addressing barriers.
Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient care delivery.
Coordinates and facilitates patient care progression throughout the continuum.
Collaborates with physicians and the multidisciplinary team to facilitate care, monitor progress, and ensure quality, efficiency, and cost-effectiveness.
Facilitates timely completion and reporting of diagnostic testing, treatment plans, and discharge plans.
Modifies the plan of care as necessary to meet ongoing patient needs.
Communicates relevant information to the care team and assigns appropriate levels of care.
Completes all required documentation.
Coordinates and communicates with providers and care team members regarding the discharge plan.
Ensures all critical elements of the plan of care, including discharge plans, are communicated to the patient/family and healthcare team.
Coordinates post-discharge needs with providers, such as Durable Medical Equipment, Home Health needs, medications, and other supplies.
Proactively identifies and resolves issues impeding diagnostic, treatment progress, and discharge.
Schedules patient follow-up with PCP or specialist within 7 days of discharge.
Reconciles discharge medication and works with PCP and clinical pharmacist for post-discharge review.
Reviews and evaluates patients to ensure they meet criteria for home health admission or other transitional care institutions.
Tracks and monitors readmissions to acute care facilities and assists with re-hospitalization reduction initiatives.
Works with the clinical team to establish care programs to help prevent readmissions and hospitalizations.
Obtains patient medical records from acute care facilities.
Utilizes advanced conflict resolution skills to ensure timely issue resolution.
Identifies at-risk populations using approved screening tools and follows established reporting procedures.
Refers cases and issues to the clinical leadership team and follows up as indicated.
Refers appropriate cases for social work intervention as needed.
Collaborates and communicates with external case managers.
Initiates and facilitates referrals for home health care, hospice, medical equipment, and supplies.
Actively participates in clinical performance improvement activities.
Uses data to drive decisions and plan/implement performance improvement strategies related to case management.
Collects, analyzes, and addresses variances from the plan of care with the multidisciplinary care team.
Documents assessments, phone calls, and patient interactions in the Electronic Medical Record in a timely manner.
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency.
Performs other duties as assigned within the nurse’s scope of practice.

Requirements

Knowledgeable of the Four Elements of the Coleman Model.

Skills

Advanced conflict resolution skills

Education Level

Bachelor’s Degree in Nursing or healthcare related field
Master’s Preferred

Equal Opportunity

Suvida Healthcare provides equal employment opportunities to all Team Members and applicants for employment and prohibits discrimination and harassment of any type with regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.