Care Manager - Care Transformation - FT - Day

Stormont-Vail HealthCare, Inc.; Topeka (KS); On-site; USD 65,000 - 90,000; Full time

Job summary

Stormont Vail HealthCare, Inc. seeks a Care Manager to collaborate with patients and health care teams, coordinating care across primary care, specialists, and hospitals.

The role emphasizes transitions of care, evidence-based guidelines, and performance feedback to improve health outcomes and reduce readmissions. Education includes a BSN preferred with 2 years of nursing experience in acute or ambulatory settings and RN licensure in KS; BLS required within 90 days of hire.

Qualifications

• Bachelor's degree required or BSN preferred.
• Case/care management experience in acute or ambulatory settings preferred.
• Lifesaving BLS certification within 90 days of hire.

Responsibilities

• Actively participates in clinic redesign and PCMH expansion.
• Collaborates with primary care and social work staff to coordinate care.
• Pulls data from multiple systems to create performance pictures.
• Implements data-driven interventions and monitors outcomes.
• Guides patients through the health care system and coordinates post-acute plan.
• Maintains timely documentation in electronic records.

Skills

Clinical judgment

Organization

Interpersonal skills

Communication

Multi-tasking

Self-directed learning

Leadership

Education

Bachelor's degree

BSN preferred

Tools

Electronic health records (EHR)

Job description

Position Status:Full timeShift:First Shift (Days - Less than 12 hours per shift) (United States of America)Hours per week:40Job InformationExemption Status: Non-ExemptA Brief OverviewThe Care Manager serves in an expanded nursing role to collaborate with patients and their health care team including Primary Care Providers, specialists, and hospitals to provide a model of care that ensures the delivery of quality, efficient and cost-effective healthcare services across the continuum. The Care Manager functions as a coordinator of patient care, assesses, plans, implements, monitors, and evaluates all options and services with the goal of optimizing the patient's health status. The Care Manager integrates evidence-based clinical guidelines, preventative guidelines, protocols, and other metrics in the development of transitions of care plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare for the targeted high-risk population. The Care Manager monitors patients across the health continuum with a focus on effective and safe transitions through the healthcare system with a goal to optimize resources and reduce avoidable readmissions back to acute care. The Care Manager manages performance feedback metrics to further refine the care model to maximize clinical, quality, and fiscal outcomes for the targeted population. The delivery of professional nursing care at Stormont-Vail HealthCare is guided by Jean Watson's Theory of Human Caring and the theory of Shared governance, both of which are congruent with the mission, vision, and values of the organization.Education QualificationsBachelor's Degree Bachelor's of Science in Nursing (BSN) PreferredExperience Qualifications2 years Nursing experience in an acute or ambulatory setting. RequiredCase/care management experience. PreferredSkills and AbilitiesDemonstrates prudent professional and clinical judgement, effective problem solving skills, critical thinking, excellent organizational and interpersonal skills, creativity, flexibility, and the ability to multi-task.Demonstrates ability to be self-directed and purposeful in seeking the necessary knowledge and skills to enhance professionalism in order to provide high-quality care.Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.Demonstrates ability to work autonomously and be directly accountable for practice.Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, priority setting, and work organization.Licenses and CertificationsRegistered Nurse - KSBN RequiredBasic Life Support - BLS Required within 90 days of hire.What you will doActively participates with clinic redesign and Patient Centered Medial Home (PCMH) expansion. Collaborates with primary care staff, social work staff, and other care team members to ensure optimal care coordination for the patient.Establish and maintain a supportive, collegial role with primary care practices engaged in improvement activity, particularly including assigned practices and their individual improvement team members.Initiates communication with patients upon learning they have been identified as high risk / targeted population.Pulls data from multiple systems and merge together to create a complete performance picture related to targeted populations. Implements interventions based on data and established guidelines. Monitors data for trends and individual outliers. Analyzes data for process improvement opportunities to impact patient outcomes.Optimizes patient care transitions by: o Assuring an appropriate post-acute plan and utilization of services o Assisting the post-acute team in development of an appropriate discharge plan for post-acute discharge. o Assures collaboration with primary care, social work & PCP care manager, other care team members, and community supports to ensure optimal care coordination for the patient.Guides patients through the health care system o Facilitates interaction and communication with health care staff providers. o Provides disease/treatment specific education to both patients and families o Oversees scheduled appointment(s) o Oversees patient testing and admissions o Reviews patient records o Efficiently documents medical information using the appropriate forms and/or electronic applications o Collects and tracks data related to targeted populations -Implements interventions based on data and established guidelines -Monitors data for trends and individual outliers - Analyzes data for process improvement opportunities to impact patient outcomesParticipates in system wide/department patient care quality improvement activities as well as standards developments. Works closely with the cross-functional teams to define analysis needs, identify trends and propose solutions.Appropriately delegates tasks and duties in the direction and coordination of health care team members, patient care, and department activities in accordance with the Kansas State Nurse Practice Act; demonstrates knowledge of KSNPA statutes and regulations.Travel Requirements20% Driving between facilities.Required for All JobsComplies with all policies, standards, mandatory training and requirements of Stormont Vail HealthPerforms other duties as assignedPatient Facing OptionsPosition is Patient FacingRemote Work GuidelinesWorkspace is a quiet and distraction-free allowing the ability to comply with all security and privacy standards.Stable access to electricity and a minimum of 25mb upload and internet speed.Dedicate full attention to the job duties and communication with others during working hours.Adhere to break and attendance schedules agreed upon with supervisor.Abide by Stormont Vail’s Remote Worker Policy and will review and acknowledge the Remote Work Agreement annually.Remote Work CapabilityHybridScopeNo Supervisory ResponsibilityNo Budget ResponsibilityPhysical DemandsBalancing: Occasionally 1-3 HoursCarrying: Occasionally 1-3 HoursClimbing (Ladders): Rarely less than 1 hourClimbing (Stairs): Rarely less than 1 hourCrawling: Rarely less than 1 hourCrouching: Rarely less than 1 hourDriving (Automatic): Occasionally 1-3 HoursDriving (Standard): Occasionally 1-3 HoursEye/Hand/Foot Coordination: Occasionally 1-3 HoursFeeling: Occasionally 1-3 HoursGrasping (Fine Motor): Occasionally 1-3 HoursGrasping (Gross Hand): Occasionally 1-3 HoursHandling: Occasionally 1-3 HoursHearing: Occasionally 1-3 HoursKneeling: Occasionally 1-3 HoursLifting: Occasionally 1-3 Hours up to 25 lbsOperate Foot Controls: Occasionally 1-3 HoursPulling: Occasionally 1-3 Hours up to 25 lbsPushing: Occasionally 1-3 Hours up to 25 lbsReaching (Forward): Occasionally 1-3 Hours up to 25 lbsReaching (Overhead): Occasionally 1-3 Hours up to 25 lbsRepetitive Motions: Occasionally 1-3 HoursSitting: Occasionally 1-3 HoursStanding: Occasionally 1-3 HoursStooping: Occasionally 1-3 HoursTalking: Occasionally 1-3 HoursWalking: Occasionally 1-3 HoursWorking ConditionsBurn: Rarely less than 1 hourChemical: Rarely less than 1 hourCombative Patients: Rarely less than 1 hourDusts: Rarely less than 1 hourElectrical: Rarely less than 1 hourExplosive: Rarely less than 1 hourExtreme Temperatures: Rarely less than 1 hourInfectious Diseases: Occasionally 1-3 HoursMechanical: Rarely less than 1 hourNeedle Stick: Rarely less than 1 hourNoise/Sounds: Occasionally 1-3 HoursOther Atmospheric Conditions: Rarely less than 1 hourPoor Ventilation, Fumes and/or Gases: Rarely less than 1 hourRadiant Energy: Rarely less than 1 hourRisk of Exposure to Blood and Body Fluids: Rarely less than 1 hourRisk of Exposure to Hazardous Drugs: Rarely less than 1 hourHazards (other): Rarely less than 1 hourVibration: Rarely less than 1 hourWet and/or Humid: Rarely less than 1 hourStormont Vail is an equal opportunity employer and adheres to the philosophy and practice of providing equal opportunities for all employees and prospective employees, without regard to the following classifications: race, color, ethnicity, sex, sexual orientation, gender identity and expression, religion, national origin, citizenship, age, marital status, uniformed service, disability or genetic information. This applies to all aspects of employment practices including hiring, firing, pay, benefits, promotions, lateral movements, job training, and any other terms or conditions of employment.Retaliation is prohibited against any person who files a claim of discrimination, participates in a discrimination investigation, or otherwise opposes an unlawful employment act based upon the above classifications.