Care Manager RN ACO

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Central Maine Healthcare
April 25, 2022
Lewiston, Maine
Job Type


Care Manager RN ACO

locations Lewiston, Maine
time type Full time
posted on Posted 4 Days Ago
job requisition id R3611

At Central Maine Healthcare our team members are committed to providing exceptional care and experiences for our community and for each other every day.

Position Summary: The Care Manager facilitates the coordination of clinical care with a multidisciplinary team approach for the assigned patient population. Serves as an advocate for the patient and their significant others, assisting the navigation through the health care continuum, implements and coordinates care progression, monitors and evaluates options and services to meet individual’s health needs through effective communication, collaboration, coordination and securing services necessary to promote optimal health outcomes. Participates in establishing standards of care and managing variances from those standards. Considers clinical and financial aspects of patient care when carrying out his/her duties. Ensures that Ensures that discharge plans are coordinated with physicians, the multi-disciplinary team, providing care for the patient, external case managers, the patient and significant others who have an ongoing caring relationship with the patient. Duties and Responsibilities: Patient Advocacy: 1. Includes patient input into all care planning and respects the rights of the patient self-determination in directing healthcare decisions. Collaborates with all members of the healthcare team to ensure the patients’ story is known. 2. Provides information to patients or collaborates with others to provide appropriate information to patients to ensure informed consent for all treatments and options of care. 3. Facilitates obtainment of advanced directives as indicated ensuring the patient’s wishes are honored by the healthcare team. 4. Demonstrates respect for cultural diversity issues that may affect the plan or care and/or desired outcomes. 5. Identifies opportunities and makes referrals to the ethics committee, palliative care services, or provide resources to obtain legal counsel as indicated to ensure quality patient care and outcomes. 6. Identifies possible abuse or neglect situations and complete mandated legal reporting processes according to policy and procedural regulations. 7. Assist with the identification of the patient/family spokesperson to ensure continuation of care planning and treatment. Clinical Management/Coordination: 1. Conducts an initial assessment of all assigned patients by reviewing the patient medical record and utilizing appropriate analytics software information to determine patient risk. 2. Establishes pre and post hospitalization functional status/abilities relevant to the clinical situation. 3. Establishes care plans to ensure patient is receiving the appropriate level of care and is progressing according to the plan of care, by monitoring outcomes determined by the impact of interventions. 4. Ensures progression of patient’s clinical care including mobility, elimination, adequate nutrition, etc. through collaborative practice efforts with nursing and the medical staff. Intervenes if discrepancies are identified. 5. Proactively identifies and coordinates the arrangement for, and participates in, patient/family conferences to ensure a realistic, efficient and effective plan of care is in place. 6. Provides early identification and referral for post-hospital services; monitors patient for changes in discharge needs collaborating with multi-disciplinary team members to determine the patient’s current status. 7. Participates in patient/care giver education when needed; interdisciplinary team to provide education in areas of expertise. 8. Assures all patients, including those who do not require post-hospital services are progressing towards planned discharge goals; serves as a resource to nursing staff on these discharges as needed. 9. Maintains awareness of evidenced based clinical practices for patients’ medical conditions in the area of assignment. 10. Assess high-risk patients who exhibit behaviors that are maladaptive to the adjustment of the illness and /or disability and then meets regularly with patients and families to enhance coping skills, adjustment to disease process, and strengthen the natural support network. Documents Interactions. Develops/Communicates Discharge Plans: 1. Collaborates with community- based and other care management staff to evaluate and modify age appropriate discharge plans as indicated. 2. Assesses patient/care giver ability to perform home care functions. 3. Interfaces with various agencies to arrange discharge services such as home care, durable medical equipment, skilled placement and transportation. 4. Actively collaborates with colleagues to assure psychosocial and discharge needs of patient are addressed. 5. Validates that all post discharge needs are in place prior to patient being discharged. 6. Validates appropriate patient transportation arrangements are in place prior to date of discharge/transfer. 7. Identifies patients at risk for extended length of stay, readmission or complex discharge needs. Identifies Barriers: 1. Identifies clinical, operational, financial and/or social barriers to patient care progression; intervenes and removes barriers that impede optimal patient care affecting patient outcomes or discharge needs; intervenes to address issues having a negative impact. 2. Elevates barriers that impede optimal patient care to the Director, ACO Operations 3. Identifies high risk patients at risk for extended lengths of stay, readmission or complex needs. 4. Identifies resource utilization patterns and variations in clinical practice patterns and intervenes to correct and/or report trends to the Director, ACO Operations 5. Identifies variations from the plan of care or clinical map and utilizes information to revise the plan of care and/or intervene so that standards of care can be met whenever possible and appropriate to the patient’s situation. Documentation Requirements 1. Documents legibly and concisely follow established policies and procedures. 2. Maintains documentation of the discharge plan of care in accordance with CMMC and departmental policy, procedures, and protocols. 3. Provides written documentation that is consistent with clinical observations and supports verbal reports. Regulatory: 1. Maintains knowledge of federal, state and other regulatory agency rules & regulations including The Joint Commission, Center for Medicare and Medicaid Services (CMS), Maine Department of Health and Human Services (DHHS), etc. 2. Maintains current knowledge of Medicare, Medicaid and other third party reimbursement requirements including patient lifetime reserve days, Skilled Nursing Facility (SNF) benefit status, etc. to ensure accurate management and planning for transition management. 3. Ensures that a self and/or team member will serve as the patient’s advocate for third party coverage of patient needs, dialoguing with payer as needed. 4. Prior to, or on admission, initiates discharge planning and utilization review needs of the patient/family according to recognized standards. Departmental/Leadership/Personal Growth: 1. Performs duties in accordance with Care Management department and CMHC policies, procedures and protocols. 2. Incorporates the CMHC mission statement and customer service policy into the delivery of care provided to patients and families. 3. Demonstrates initiative to seek new knowledge and expands professional practice through educational, coaching and supervision opportunities. 4. Identifies continuing education needs and assumes responsibility for own professional development. 5. Establishes yearly performance goals and demonstrates progression towards achieving those goals. 6. Serves as a preceptor for new staff. 7. Participates in appropriate local, regional, and national professional organizations. 8. Demonstrates communication skills that reflect a positive message with creative and collaborative problem solving skills. 9. Demonstrates communication skills that reflect a positive message with creative and collaborative problem solving skills. 10. Provides input into strategic planning for the Care Management department. Quality/Performance Management: 1. Maintains awareness of corporate goals related to care management and need to participate and ensure the attainment of goals. 2. Participate in, minimal of (1) performance improvement project team that affect the quality and cost of care and assist with measures and analysis of measures and outcomes. 3. Identifies and makes recommendations for improved practice utilizing evidence-based research. 4. Participates in the development of care management practice standards and executes consistent standards of care. 5. Participates in the education to staff regarding appropriate bed status and documentation that reflects patient acuity and resource utilization as appropriate. 6. Reports errors and incidents in accordance with CMHC policies and procedures. Identifies potential risk management or quality issues and resolves through intervention or refers as appropriate. Customer Service: Interacts with all individuals in a consistent manner, providing attention, support and assistance to foster an environment of exceptional personal service. 1. Maintains a pleasant and helpful demeanor, and presents a professional appearance toward all internal and external customers at all times. 2. Consistently initiates interaction to provide assistance to individuals who may not be direct customers of the employee (i.e. asks patients who appear to be lost if they need assistance in finding their way). 3. Takes appropriate action to recover from a service difficulty, ensuring that the necessary action is taken to affect a resolution to the customer’s problem. 4. Conducts all work activities with respect for coworkers, including the maintenance of a pleasant and professional environment, fostering calmness during stressful situations. 5. Interacts with supervisory personnel in a professional, supportive and courteous manner, venting emotions appropriate to time and place. Organizational Requirements: 1. Adheres to dress code, appearance is neat and clean. 2. Completes annual education requirements. 3. Reports to work on time and as scheduled, completes work within designated time. 4. Wears identification while on duty, uses computerized punch time system correctly. 5. Completes inservices and returns in a timely fashion. 6. Attends annual review and department inservices, as scheduled. 7. Attends staff meetings. Reads and returns all monthly staff meeting minutes. 8. Represents the organization in a positive and professional manner. 9. Complies with all organizational policies regarding ethical business practices. 10. Communicates the mission, ethics and goals of the facility, as well as the focus statement of the department. Confidentiality: Maintains confidentiality of information at all times. 1. Consistently maintains confidentiality of all information gained during the course of employment, respecting the privacy of others. 2. Understands and maintains the confidentiality of information communicated directly from the supervisor, including discussions of a counseling nature. 3. Follows policies and procedures related to medico legal matters, including confidentiality, amendments of medical records, patient rights, medical records as legal evidence and informed consent 4. Copies records according to policy, assuring the appropriateness of the individual requesting information from the record prior to copying, faxing, or phoning any portion of the record. Safety: Demonstrates an understanding of fire and electrical safety, infection control, body mechanics, and related areas, as appropriate to position. 1. Attends mandatory in-services on fire safety, electrical safety, infection control, and body mechanics. Successfully completes competency-based training in each area. 2. Follows all employee health procedures, incident reporting, and infection control requirements at all times, as appropriate to the position. 3. Uses proper body mechanics at all times as required by the physical demands of the position. 4. Maintains a safe work environment and performs duties of the position in a manner consistent with ensuring the safety of self and others. 5. Identifies safety needs in areas outside own work environment, recommending corrective action as appropriate. Expense Control: Performs job duties in a manner that maximizes expense control. 1. Uses supplies, equipment, and utilities in an expeditious manner 2. Consistently recommends methods to control costs while maintaining a high degree of customer service. 3. Performs job tasks efficiently and effectively resulting in no unplanned overtime. Regulatory Requirements: Meets and maintains the minimum qualifications for the position including: • Current State of Maine RN licensure. • Three (3) or more years of previous experience associated with assigned areas. • Certified Case manager preferred. Language Skills: • Able to communicate effectively in English, both verbally and in writing. • Additional languages preferred. Skills: • Basic computer knowledge. Physical Demands: For physical demands of position, including vision, hearing, repetitive motion and environment, see following description. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising client care.If you are passionate about making a difference and are looking for your next great career opportunity, we look forward to reviewing your application!

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