We are currently looking to hire a contracted RN to lead in a Care Manager role.
Essential Job Responsibilities:
Provide care management services to patients and families.
Communicate with patients and families/supports to promote participation in the development and execution of the plan of care.
Function as liaison with external providers and funding sources to maximize patient satisfaction, quality, and cost-effective outcomes.
Coordinate highly effective level of care transitions from community-based levels of care and services, such as: outpatient rehabilitation, home care, hospice, school, vocational rehabilitation, counseling, etc.
Oversee the patient follow up process to insure highly durable outcomes.
Document patient/family status and progress status on a continual basis.
Identify complex barriers and troubleshoots on non-covered medications, home modifications, non-funded equipment, etc.
Ensure access to all needed follow-up primary care and medications in order to reduce the likelihood of potential re-hospitalization.
Educate patients and families/supports on current evidence based practices related to complex /chronic disease management across the continuum of care to reduce the frequency of re-hospitalization.
Communicate with rehabilitation team regarding patient and family needs, preferences, resources, funding issues and any discharge/transition status in order to integrate the care process and minimize fragmentation in the services.
Attend and participate actively in patient team conferences by representing the needs, preferences and resources of the patient and family/supports. Identify the need for and facilitate family conferences as appropriate to assure the needs and preferences of the patient and family/supports are in unison with the goals and clinical interventions of the rehabilitation team.
Functions as a patient advocate and maintains patient confidentiality. Educate the patient, the family/supports, and members of the health care delivery team about treatment options, community resources, insurance benefits, psychosocial concerns, case management, etc., so that timely and informed decisions can be made.
Promote patient self-advocacy, choice and self-determination. Educate patients and families/supports in the appropriate use of health care services. Improve quality of care and maintain cost effectiveness on a case-by-case basis.