Care Manager, RN-Hybrid

Careabout; Mississippi; On-site; USD 70,000 - 90,000; Full time

Job summary

CareAbout Health is seeking a Care Manager, RN to provide transitional care management for patients recently discharged from the hospital. This role involves coordinating patient care, promoting patient-centered practices, and working alongside a multidisciplinary team to optimize healthcare delivery. Eligible candidates must possess a Florida RN License and significant experience in direct patient care.

Qualifications

• Must have a current FL RN License.
• 5 years of direct patient care experience required.
• Care Management experience preferred.

Responsibilities

• Support patients discharged from the hospital for transitional care management.
• Develop relationships with healthcare providers to coordinate care.
• Ensure follow-up primary care visits occur within 24 hours of discharge.

Skills

Strong communication skills

Problem-solving abilities

Organizational skills

Interpersonal skills

Education

Florida RN License

Degree in Nursing

Tools

MS Office (Word, Excel, Outlook, PPT)

Job description

CareAbout Health is a managed services organization (MSO) that provides expert advice, resources, tools, and other support to its portfolio of medical groups and healthcare focused companies. CareAbout Health is helping align incentives to create a world where patients, providers, and payers work together in a seamless, coordinated manner toward common goals: higher quality, lower cost, better outcomes.

Role Title: Care Manager, RN

FLSA Category: Non-exempt

Role Location: Boynton Beach, FL

Reporting Relationships:

This position reports to the Director of Care Management.

Role Summary and Responsibilities:

The Care Manager, RN (RN-CM) will support patients recently discharged from the hospital for transitional care management within a multidisciplinary healthcare team in a primary care setting, focusing on coaching and coordination of care for patients needing navigation and follow up. The RN-CM will identify the needs of complex members and assist with the practice to develop processes for managing the high-risk member population. This person will promote patient-centered care, working with primary care providers and medical home team members. The RN-CM has a key role in the transformation of the medical practice participating in VBC/APM contracts.

Key Responsibilities / Essential Functions:

The duties include, but are not limited to:

Develop constructive relationships with local hospitals admission offices, case managers and discharge planners.

Work to develop systems, processes, and initiatives to engage these entities in relevant case management activities with high-risk members of the practice ensuring necessary post discharge needs are met.

Monitor to ensure care is coordinated with home care agencies, specialists, or other resources needed.

Monitor to make sure follow-up primary care visits are obtained within 24 hours of hospital discharge.

Conduct follow-up to ensure that initial patient assessment and post-visit consultation includes a comprehensive medical, psychosocial, and that functional assessment of the patient are all completed and in order as identified by the patient centered medical home.

Communicate with and coach patients to ensure they are aware of discharge instructions, have necessary prescriptions, access to medications, and understand how to take the necessary medications, including what to look for regarding adverse events as per their care givers instructions.

Monitor that appropriate home care, hospice care, and other ancillary services (DME, infusion services etc.) are in place and are being delivered as directed by the care team.

Coordinate necessary referrals and authorizations within care management areas.

Facilitate the information flow between hospitals, long-term care, specialists and home health representatives and the care team.

Work with physicians and office staff to help identify high risk, high need, and potentially high-cost patients.

Assist physicians and care teams in implementing processes for best practices for preventive services, chronic care, and disease management.

Work collaboratively with physicians and the care team to ensure patient adherence to medical plan of care, including all appropriate preventive and disease-specific screenings, interventions, treatment goals – including self-management goals, and contract schedules.

Coordinate care and communicate with multiple providers, both within and external to the practice.

Identify and utilize cultural and community resources.

Verify that practice has necessary behavioral health screening tools (depression / substance abuse), and all members are receiving appropriate screening and behavioral health interventions.

Facilitate any necessary follow-up behavioral health needs with local behavioral health providers.

Attend required training and collaboration sessions [i.e., learning sessions, care management meetings, and practice team meetings] as scheduled.

Assess patient needs and develop a plan of action to address needs in collaboration with the primary care physician.

Provide and facilitate open communication, regarding patient status, with physicians and office staff.

Obtain records from other physicians/labs/diagnostic centers as requested by the physicians and as needed for care coordination efforts.

Non-Essential Functions:

Other duties, as assigned.

Qualifications:

Florida RN, degree, required. Must have a current FL RN License.

Care Management experience preferred.

Certified Case Management (CCM) certification preferred.

APM (CPC+, BPCI, MSSP) and MA experience preferred.

Experience in acute inpatient, rehabilitation, sub-acute, skilled facility, home care, ambulatory care management, or managed health plan.

5 years of direct patient care experience required.

Principles of utilization management; Case/care management principles; Health care contracts and benefit eligibility requirements; Hospital structures and payment systems; Basic PC skills (MS Word/Outlook/PPT/Excel).

Ability to use independent judgment and to manage and impart confidential information.

Ability to analyze and solve problems requires details, data and facts that must be analyzed and challenged prior to making decisions.

Strong communication and interpersonal skills.

Ability to clearly communicate medical information to professional practitioners and/or the public.

Excellent organization, prioritization, follow up, analytical and time management skills with ability to handle multiple priorities and deadlines.

Good interpersonal skills, sense of urgency, being proactive and ownership for one’s work.

Dependable, with strong work ethic and extremely high degree personal integrity.

Ability to deal with multiple interruptions on a continual basis that must be met with a friendly exchange with others.

Ability to develop and implement new approaches to improve processes, procedures, or the general work environment.

Ability to review critical issues, effectively solve problems and create action plans.

Physical Requirements:

Mainly sedentary.

Sitting at the desk most of the day.

Standing or walking less than two hours per day.

Lifting no more than ten pounds on rare occasions.

Must be able to work at a computer and answer phone calls on a regular basis.

Compensation is based on the level and requirements of the role.

Salary within our ranges may also be determined by your education, experience, knowledge, skills, abilities, and location, as required by the role, as well as internal equity and alignment with market data.