Nurse Care Manager - Suvida Healthcare LLC

• Earn Trust
• Building Relationships
• Creating Joy
• Doing Right
• Improving Every Day
• Moving Forward

• Oversees chronic care and transitions of care management of high-risk patients within their care teams and neighborhood centers
• Serves as a resource to the multidisciplinary team for the management of complex patients, including chronic care management assessments and care plans
• Performs triage for patients via phone and addresses issues appropriately or forwards message to appropriate party for further interventions
• Responsible for ensuring efficient, organized patient transitions from acute and post-acute setting to home or other transitional care facility
• Perform comprehensive assessments for both physical, mental, and social risk factors that support individual patient needs while identifying and addressing barriers
• Coordinates/facilitates patient care progression throughout the continuum.
• Works collaboratively and maintains active communication with providers, nursing, and other members of the multi-disciplinary care team to effect timely, appropriate patient management.
• Proactively identifies/resolves issues impeding diagnostic, treatment progress, and discharge.
• Coordinates and communicates with providers and all involved care team members in the discharge plan to ensure their participation and readiness
• Communicates with and the patient and family regarding the discharge planning process to minimize any anxiety or apprehension and optimize patient outcomes and patient satisfaction
• Knowledgeable of the Four Elements of the Coleman Model
• Coordinates post-discharge needs with providers, such as Durable Medical Equipment, Home Health needs, medications, and other supplies
• Schedules patient for follow up with PCP or specialist within 7 days of discharge
• Reconciles discharge medication and works with PCP and clinical pharmacist for review post-discharge
• Reviews and evaluates patient to ensure that the patient meets criteria for home health admission or admission to other transitional care institutions
• Coordinates discharge needs with patients, caregivers, and acute facility providers and ensures the arrangements with post-acute care providers and care team members are completed
• Tracks and monitors readmissions to acute care facilities and assists with re-hospitalization reduction initiatives
• Works with clinical team to establish care programs to help prevent readmissions and hospitalizations.
• Collaborates with the multidisciplinary care team to ensure awareness of discharges needing specific care and coordination
• Obtains patient medical records from acute care facilities, including orders, referrals, care team documentation, diagnostic testing results, and acute care visit summaries
• Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.
• Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated patients; monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis: completion and reporting diagnostic testing, treatment plan and discharge plan; modification of plan of care, as necessary, to meet the ongoing needs of the patient; communicates relative information to the care team; assignment of appropriate levels of care; completion of all required documentation
• Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
• Identifies at-risk populations using approved screening tool and follows established reporting procedures.
• Refers cases and issues to clinical leadership team and follows up as indicated.
• Ensures that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care
• Communicate with patients and caregivers to assess needs and develop an individualized continuing care plan in collaboration with providers.
• Collaborates and communicates with multidisciplinary care team and with transitions of care team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluation
• Refers appropriate cases for social work intervention as needed
• Collaborates/communicates with external case managers. Initiates and facilitates referrals for home health care, hospice, medical equipment and supplies.
• Actively participates in clinical performance improvement activities
• Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical, and patient satisfaction data
• Collects, analyzes, and addresses variances from the plan of care with multidisciplinary care team
• Documents assessments, phone calls, and patient interactions in the Electronic Medical Record in a timely manner
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency
• Other duties as assigned

• Minimum 2 years of experience as a Registered Nurse

• Minimum 2 years of experience in utilization management, case management, chronic care management, discharge planning, transitions of care management, cost/quality management program, and/or other related field
• Available to work during assigned clinic business hours
• Current working knowledge of chronic care management, discharge planning, utilization management, case management, performance improvement and/or managed care reimbursement
• Competency in chronic care management, pre-acute, and post-acute venues of care, and post-acute community resources
• Excellent interpersonal communication, leadership, collaboration, and negotiation skills
• Effective oral and written communication skills
• Strong technical skills including data analysis and management, competency in Microsoft Office suite, and Electronic Medical Records
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components
• Ability to work independently and exercise sound judgment in interactions with providers, payors, patients, and their families
• Ability to travel for orientation and as needed (10% or less)
• Experience with Medicare Advantage, Value-based care, and/or Managed Care desirable
• Bilingual/Bicultural (English and Spanish) Preferred

• Bachelor's Degree in Nursing or healthcare related field
• Master's Preferred
• Active Arizona or Multi-state Compact Registered Nurse License

PI239339695