RN SNF Care Manager
Under the direction of the Manager of Care Management, the Extended Care Facility Care Manager (ECF CM) coordinates and manages all aspects of a Steward patient's skilled nursing or acute rehabilitation hospital admission through a safe and seamless transition to the next level of care. The ECF CM establishes active partnerships with patients/families and clinical partnerships with facility leadership staff, SNFists/rounding team and the Steward Health Care Network Medical Director.
- Concurrently reviews patient's records to collect data to carefully understand patient’s needs by scrutinizing background history, understanding current needs, and arranging for patient well-being.
- Communicates admission (and discharge) info to PCP via standard process and collaborates with PCP office to understand patient's needs and circumstances to assist in preparation for an adequate discharge plan.
- Using industry guidelines, assesses appropriateness of admission, level of care, and length of stay.
- Coordinates with other disciplines to facilitate patient's individual needs, makes plans to resolve unexpected care requirements, and anticipates and identifies variances in the care process related to those identified needs.
- Assists in development, implementation, and revision of individual treatment plans; assures that services provided are specified in the Treatment Plan and monitors progress toward treatment goals, including documentation of daily improvement in patient's condition or otherwise notes lack of improvement for reassessment of appropriateness of treatment plan.
- Communicates with nursing home physicians regularly to evaluate the status of each patient. Collaborates with other team members to ensure appropriate interventions are implemented. Communications must be performed as frequently as is needed to ensure care is appropriate according to patient status.
- Prioritizes caseloads according to patient complexity, length of stay, and risk for readmission.
- Coordinates with other disciplines to facilitate patient receiving the required care at the expected time including plan of care to reduce incidence of re-admission to acute care setting, including physical, occupational, and rehabilitative therapy.
- Coordinates transfers to a lower level of care, home health referrals, and durable medical equipment delivery to facilitate discharge from skilled nursing facility.
- Measures effectiveness and outcomes of the care plan and collaborates with the health care team for quality improvement.
- Interacts with patient and family providing transition plan for treatment goals and post-discharge needs.
- Assesses and makes referrals to appropriate internal resources to allied professionals such SW, pharmacist, and health and wellness educators, and to other SHCN programs such as Ambulatory Care Management (formerly known as CCPM) as well as to external resources such as community resources to facilitate patient progression toward expected goals/outcomes.
- Has a working knowledge of the financial aspects related to a variety of payer sources.
- Maintains required medical documentation for case management activities in Optum1 (electronic medical records), according to the standard of work.
- Follows standards of work and consistently maintains department established caseloads and timeframes for case completion. Participates in the refinement of and development of new standards of work and assists in Performance Improvement work such as case audits and root cause analyses of ER visits and readmissions from post-acute facilities.
- Meets regularly 1:1 with the Manager of Care Management to review caseload and discuss barriers/challenges and review performance compared to current targets/expectations.
- Participates in regular 'huddles' with manager and the SHCN Medical Director to proactively identify problematic cases using the SBAR format to summarize, report, and escalate cases for assistance with resolution.
- Documents and reports all quality and patient safety events by recording and adhering to all of Steward Health Care Network's safety reporting guidelines.
- Performs all job functions in compliance with applicable federal, state, local, and company policies and procedures, including Medicare denials and appeals processes.
- Stays current with medical, nursing and pharmacological Evidence Based Guidelines (EBGs) for the care of patients with complex and chronic conditions.
- Performs other duties as needed.
- Graduate of a state-approved school of nursing; BSN preferred.
- Possess a current unrestricted RN license in the Commonwealth of Massachusetts. Must maintain Basic Cardiac Life Support (BCLS) certification. Certified Case Management (CCM) or CCM eligible strongly preferred.
- Minimum of 3-5 years’ relevant clinical nursing experience required.
- Experience in Care Management is strongly preferred.