Reg Nurse Care Mgmt Coord - 23127

The Registered Nurse (RN) Care Management Coordinator or “Care Manager” provides care management services to a panel of medically complex patients or populations of patients who have risk factors that are amenable to care management interventions.  The RN Care Manager may be assigned regionally to support one or more CHOP primary care practices and/or may be assigned to the care of patients who receive primary care outside of the CHOP Care Network.  S/he serves an advocate for patients and their families and assists them to navigate the health care system.  The RN Care Manager facilitates the continuity of a patient’s care by functioning as a liaison between primary care providers (PCPs), outpatient specialty care providers and inpatient care teams, as well as payers, medical equipment suppliers, home care providers, subacute and chronic care facilities and community resources.  S/he collaborates with ambulatory, emergency department and inpatient care teams with the goals of optimizing communication among care providers, promoting seamless transitions between care settings and facilitating the appropriate use of health care resources. 

Practice

• General care coordination responsibilities:
  • Identify patients in need of care management and maintain a patient database.
  • Provide care management services to an assigned panel or designated population of patients and their families.
  • Develop and maintain patient-centered, intra-disciplinary, longitudinal plans of care and monitor patients’ progress toward care plan goals.
  • Advocate for patients and families and promote communication and collaboration to keep all care team care members informed of patients’ care needs and to ensure that patients access and benefit maximally from available health care resources.
  • Facilitate transitions across care settings.
  • Assist patients and families with access to health care services as needed, including collaboration with payers.
  • Teach, coach and counsel patients and their families to build independence and skills for self-management.
  • Monitor and evaluate patients’ outcomes and communicate outcomes to health care teams.
  • Use information systems to document and track care coordination interventions
  • Transfer patients to higher or lower levels of care management support as appropriate.
• Outpatient care coordination responsibilities:
  • Communicate regularly with PCPs and relevant specialists regarding acute and chronic patient care issues and intra-disciplinary care plans.
  • Review medical records prior to encounters and participate in outpatient visits as necessary to assist in the development and updating of care plans.
  • Participate in care team meetings to discuss active clinical issues and progress toward goals.
  • Establish routine communication plans and communicate regularly with patients and families to assess ongoing care needs and to facilitate proactive care planning, including regular telephone contact.
  • Serve as a liaison with insurers/payers, review resource utilization and eligibility and identify the need for and facilitate obtaining additional health insurance services.
  • Complete letters of medical necessity, referrals and prior authorizations as needed.
  • Collaborate with home nursing companies and Durable Medical Equipment (DME) providers.
  • Identify and develop relationships with community resources to support patient’s needs and makes referrals when appropriate.

• Inpatient care coordination responsibilities:
  • Respond to referrals from inpatient teams, primary care providers or referring hospitals/facilities prior to discharge, and provide consultation on enrollment in longitudinal care management services.
  • Establish relationships with patients who are newly enrolled in care management services prior to discharge and collaborate with the inpatient teams regarding discharge plans and anticipated outpatient care needs.
  • Serve as a longitudinal resource for inpatient teams to obtain relevant information and updates about patients during admissions, and collaborate with inpatient teams regarding outpatient care needs and discharge plans.
  • Facilitate scheduling post-discharge follow up telephone encounters and visits with the PCPs and specialists.
  • Coordinate plans for follow up visits with care providers and for laboratory and diagnostic studies after discharge.
  • Attend inpatient family meetings and care conferences when necessary to integrate inpatient care with patients’ longitudinal, intra-disciplinary care plans.
• Emergency Department care coordination responsibilities;
  • Serve as a resource to Emergency Department providers for information about patients that will inform the Emergency Department plan of care.
• General registered nursing duties (including but not limited to);
  • Obtain and document patients’ histories.
  • Perform and document physical assessments.
  • Conduct telephone triage and refer patients to appropriate services.
  • Perform and/or interpret basic laboratory tests.
     

Professionalism and Leadership

• Assist with surveys and other data collection activities to measure the effectiveness of care management interventions.
• Support strategies and changes as needed to improve the care management program.
• Serve as an institutional expert on care coordination and transition management.
   

Research

• Read, analyze and synthesize nursing and other scholarly articles and research studies; share knowledge with colleagues.
• With assistance, apply research findings to clinical practice.
• Seek opportunities to participate in research studies.
   

Learning

• Identify learning needs of self and others and assists in the development of a learning plan. 
• Apply education and training from departmental in-services and external sources to unit practices to enhance Nursing practice.
• Participate in the development/presentation of education programs.
• Demonstrate health care informatics competency in order to manage patient care, outcome data and current and emerging health care technology.
   

Resource Management

• Participate in promoting quality, efficient and cost effective care.
• Monitor own usage of supplies and equipment/identify opportunities for improvement and makes recommendations.
• Manage own time to accomplish direct/indirect care in a cost efficient manner.

Required Education: BSN

Required Experience: At least five (5) years of nursing experience

Preferred Experience:

• Pediatric experience.
• Nursing experience with a combination of outpatient and inpatient experience.

Computer Competency

• Navigation and basic search functions of the Internet using Internet Explorer
• Use of Outlook 2007 email, opening of attachments, attaching new files to emails and saving attached files to computer
• Basic use  of computers, printers, monitors, patient care devices,  and Fax machines

Information Literacy

• Use of Internet and Intranet to look up basic electronic resources for practice
  • Ability to find and print Patient Family Education Documents

Information Management Literacy

• Navigation of electronic health information records and ability to review specific patient data in a clinical information system
• Understanding of policies and procedures around timeliness of care, use of a clinical information system and support of safe nursing practice
• Ability to discuss data presented in charts and tables
• Discuss the responsibilities of each user of an electronic record related to confidentiality and privacy
• Coordination of patient care information in a fragmented environment where there is partially online and partially paper references