Nurse Care Manager

Prospect Medical Holdings, Inc. • Full-time • Johnston, RI, US • $90,000 - $100,000 / year • 1m ago

Job Description

Job Summary : The Care at Home-Registered Nurse (CAH-RN) effectively manages complex high risk patients by visiting patients at home and telephonically to support complex and chronic care needs by 1) develop a trusting relationship b) clinically assessing patients c) empathizing and identifying the challenges patients and families face, d) help patients and families in prioritizing and resolving the challenges in recovery by ensuring PCP appointments, assessing home situation, support available from family & caregivers, teaching patients and families about key disease conditions as relevant, ensuring education to help with medication adherence to ensure steady recovery and prevent unnecessary hospital admissions. The CAH-RN will work in collaboration with the patients’ family members, caregivers and PCP to solicit and ensure additional help required by patients as they move through their health continuum. In addition, CAH-RN will prioritize patients’ medical, environmental and psychosocial needs with the goal of optimizing medical Care at Home- where every one of our patients want to be!

Responsibilities

Effectively manages patients either telephonically or onsite during their hospitalization to ensure the appropriate level of care is provided for the patient’s severity of illness. Utilizes the appropriate tests and diagnostics in the right facilities to facilitate the highest level of care in the most efficient manner. Communicates effectively with the facility staff and to gather clinical information through verbal and written communications and provides timely and accurate responses to request information or provide authorization decisions. Updates clinical information in the electronic medical management record system with treatment plan, objectives, results, and next steps.|Documents all information accurately with approved criteria utilizing the goal length of stay. Initiates and continues direct communication with health care providers involved with the care of the member, including the IPA or Hospitalist Group if applicable, to obtain complete and accurate information. Applies appropriate benefits. Utilizes current approved criteria along with clinical experience to make authorization decisions. Identifies cases not meeting criteria and provides clinical information and rationale to the Medical Director for review and determination. Actively participates in daily rounds with current and accurate clinical information.|Collaborates with Medical Director to determine optimal outcome for patients to include appropriate level of care, post-acute services, and community resources. Responsible for timely development of denial letter language and member/provider notification regarding Medical Director’s review determination.|Onsite/telephonic interaction o serve as a Concierge for the SNF Management team and patients to avoid errors in discharge, ensure PCP/specialist appointment., Identifies post discharge care needs and refer to the appropriate outpatient programs and/or providers.|Interacts with hospitalists, facility staff and patients daily to evaluate plan of care including discharge planning to determine that patients are receiving quality care and appropriate discharge disposition. Applies medical knowledge to authorize outpatient services as an alternative to hospitalization when appropriate.|Identifies and reports under and over utilization of medical services, delays in service by hospital or treatment and quality care issues to the Medical Director, and/or the QI department. Actively participates in internal quality and workflow enhancement projects, and other duties, as assigned. Identifies and reports departmental operational issues and resource needs to the appropriate management personnel.

Qualifications

Three to five (3-5) years experience in a Medical Group or Health Plan setting with strong clinical skills and critical thinking skills. Four (4) years experience in managed care setting, with previous SNF experience. Experience with Microsoft Office Word. Make independent decisions. Knowledge of nationally recognized criteria InterQual, etc. Maintains strong working relations with internal and external customer. Effectively articulates clinical and non-clinical information to persons of all levels. Communicates positively and effectively. Maintains member confidence and protects operations by keeping claim information confidential in compliance with HIPPA requirements.Knowledge of NCQA, Medicare, Health Plan, DHS and State standards and other regulatory requirements.High school diploma or GED. Graduate of accredited nursing school.Active, unrestricted RN license

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