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About the Role
The Nurse Care Manager will collaborate with Suvida Healthcare’s multidisciplinary care team to provide high-quality care for high-risk patients. They will develop organization-wide approaches to problem-solving, tracking, and managing complex cases and populations, while planning effectively to meet patient needs, identify social determinants of health, manage chronic conditions, and promote efficient resource utilization.
Responsibilities
- Oversees chronic care and transitions of care management of high-risk patients within their care teams and neighborhood centers.
- Serves as a resource to the multidisciplinary team for the management of complex patients, including chronic care management assessments and care plans.
- Performs triage for patients via phone and addresses issues appropriately or forwards messages for further interventions.
- Ensures efficient, 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 to support individual patient needs while 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 for designated patients, monitoring progress and intervening as necessary.
- Coordinates and communicates with providers and care team members in the discharge plan to ensure participation and readiness.
- Ensures all elements critical to the plan of care, including discharge plans, are communicated to the patient/family and healthcare team and documented.
- 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 admission to 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, including orders, referrals, care team documentation, diagnostic testing results, and acute care visit summaries.
- 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, including fiscal, clinical, and patient satisfaction data.
- 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 that are within the nurse’s scope of practice.
Requirements
- Knowledgeable of the Four Elements of the Coleman Model
Skills
- Chronic care management
- Transitions of care management
- Complex patient management
- Triage
- Comprehensive assessments
- Collaboration
- Care coordination
- Discharge planning
- Conflict resolution
- Data analysis
- Performance improvement
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.