Job Summary:
The Integra Transitions NCM collaborates with hospitals and skilled nursing facilities to pursue cost-effective, quality-focused management interventions by achieving predetermined financial and clinical outcomes. Responsible for collaboration with the Integra Nurse Care Managers/Transition Managers (hospital and skilled nursing facility based) concerning quality initiatives, outcomes, etc. Responsible for providing ongoing communication with patients, continuing care coordinators, social workers, and physicians to ensure patients have appropriate resources/support in the Hospital and SNF setting and upon discharge to the community and intervening when patients are unable to be managed adequately. Tracks patients along with the continuum of care, identifying patterns that have a negative cost-quality impact and assists with the development of plans for improving care.
Duties and Responsibilities:
- Applies Case Management principles to the Hospital inpatient and Skilled Nursing Facility (SNF)-patient population to ensure appropriate utilization of resources and level of care. This includes assessing, planning, implementing, coordinating, evaluating, and collaborating with the Hospital/SNF interdisciplinary team, patients, families, and community providers.
- Assists in the facilitation of discharge planning for Integra ACO patients within the Hospital/SNF setting. This may include but is not limited to, acute rehabilitation admission, initiation or resumption of visiting nurse services, referral to other outpatient providers, transportation, and initiation of outpatient Infusion therapy.
- Assists in the identification of patients for Case Management and Social Service referrals during the review process.
- Completes all documentation in a timely manner in Epic.
- Acts as a resource to the Integra SNF NCM, Integra Transition Managers, ED Hospital Liaison, and Community Care Managers.
- Engages in process improvement activities that are focused on efficient care delivery and promotes positive clinical and quality outcomes including reducing unnecessary admissions, readmission rates, and flow metrics.
- Performs related duties as required.
Requirements:
- Registered Nurse with bachelor’s degree in nursing or equivalent, Master’s Degree preferred.
- Certification in Case Management with current RN Rhode Island license.
- Minimum of 5 years related clinical Acute Care or Case Management experience required.
- Knowledge of utilization review, quality assurance, discharge planning, third party payer regulations, and community health.
- Experience demonstrating high level of interpersonal skills, both oral and written, analytical skills, leadership abilities, and effectiveness within a team environment.
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