RN - Transitional Care Coordinator-Jeff Hwy

Ochsner Clinic Foundation; New Orleans (LA); On-site; USD 68,000 - 100,000; Full time

Job summary

Ochsner Clinic Foundation in New Orleans, LA is seeking a skilled RN Case Manager to oversee identified complex patients across the care continuum. You will assess needs, develop and implement care plans, coordinate with PCPs and the multidisciplinary team to remove barriers and achieve optimal outcomes.

Responsibilities include evaluating social determinants of health, coordinating referrals, tracking progress, and ensuring documentation in the EMR.

Qualifications

• RN license in state of practice
• Experience in a clinical setting with documentation in EMR
• Experience in multidisciplinary team environment with care coordination

Responsibilities

• Collaborates with health care team, patient, and caregiver to implement a coordinated treatment plan
• Assesses social determinants of health that may affect care and refers to Social Work or CHW
• Uses case management to develop cost-effective care plans
• Coordinates referrals and appointments with care team
• Provides disease-based patient education and collaborative action plans
• Provides community resources to patients to avoid hospitalization
• Identifies quality issues and reports to leadership

Skills

Case management

Care coordination

CMS knowledge

Communication

EMR documentation

Education

Graduate of an accredited school of nursing

BSN preferred

Tools

EMR software

Microsoft Office

Job description

Exceptional care starts with exceptional people.

For us, this is more than a job- it's a calling. It's waking up each day, looking for ways to make a difference with a compassionate, inclusive and talented team. Ochsner empowers you to discover your passion, reach your potential, and Pursue Your Purpose. Exceptional care starts with exceptional people and teams. Together we are leading the way.

This job manages identified complex/catastrophic patients attributed to the organization and its Network of partner providers. Uses the case management process to assess the healthcare needs of the enrollee, identify barriers to care, develop a comprehensive treatment plan complete with specific goals and objectives, implement a treatment plan in collaboration with the PCP team and the other providers involved in the patients' care, negotiate and coordinate service for the patient, monitor and evaluate the effectiveness of the plan in achieving the goals and objectives, and change and modify the plan as needs and situations change. This job is an integral part of the multi-disciplinary care team and as such coordinated care among multiple healthcare providers, the patient's caregiver(s), community services, payors, and others involved in the care of the patient to ensure services are provided seamlessly throughout the continuum of care. Arranges and coordinates resources necessary to manage the patient's disease processes in the home environment. This job adheres to the CMSA Standards of Practice for Care Management.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties.

This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at the company's discretion.

Education

• Required - Graduate of an accredited school of nursing.
• Preferred - Bachelor's degree in nursing.

Work Experience

• Required - 3 years of experience in a clinical setting; experience documenting in an electronic medical record and using Microsoft Office; experience working in a multi-disciplinary team environment.
• Preferred - Experience in case management, care coordination or disease management.

Certifications

• Required - Current Registered Nurse (RN) License in the state of practice.
• Preferred - Certification as a Case Manager (CCM).

Knowledge Skills and Abilities (KSAs)

• Proficiency in using computers, software, and web-based applications.
• Effective verbal and written communication skills and ability to present information clearly and professionally to varying levels of individuals.
• Excellent knowledge of managed care, CMS, Medicaid and other regulatory standards/requirements and ability to use community resources and other resources to facilitate the patient's care throughout the care continuum.
• Good organizational and time management skills and ability to be self-directed and demonstrate good judgement.

Job Duties

• Collaborates with members of the health care team, the patient, and patient's caregiver(s) to develop and implement a coordinated treatment plan across the continuum
• Assesses patient for social determinants of health that may create barriers to care and/or adversely impact the care and treatment plans. Includes SDOH in the care/treatment plan and refers to Social Work or Community Health Worker as appropriate and guided by workflow/process
• Uses the case management process to develop comprehensive cost-effective plans of care for patients in care management
• Collaborates with the multidisciplinary team, Primary Care Provider, and other appropriate care providers to facilitate appropriate care and treatment of the patient
• Coordinates referrals and appointments with members of the care team
• Provides in-depth disease-based patient education and formulates collaborative action plans with patient/caregiver to achieve agreed-upon goals for self-management and to improve patient health status
• Provides community resources to patient, families and/or caregivers to avoid or reduce hospital admission through telephonic and face-to-face contact
• Identifies quality issues that may adversely affect patient outcomes and submit to department leadership
• Performs other related duties as required

The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time.

Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with a