What are the responsibilities and job description for the RN Care Manager - Geriatrics position at Billings Clinic Health System?
Under the direction of department leadership, the Care Manager provides services consisting of comprehensive care management, care coordination and care continuing care services. The Care Manager is accountable for a designated patient caseload/population and plans effectively in order to meet patient needs. The Care Manager is a support to providers and the multidisciplinary in facilitating patient care. The Care Manager strives to enhance the quality of clinical outcomes and patient satisfaction while managing the cost of care.
Essential Job Functions
Assessment
chart reviews of each assigned patient to identify potential and or actual
barriers and care needs.
transitional needs of each assigned patient
and the multidisciplinary/healthcare team to establish a plan of care that
addresses the mutually identified needs of the patient.
Interventions and Care Coordination
information and understand health care treatment and systems.
best of their ability and maintain optimal health related to their medical
condition(s). Identifies and addresses gaps in
knowledge/understanding/education related to disease management.
interacting/collaborating with patients, support systems, healthcare
professionals and community and state agencies. Serves as a liaison between
hospital, clinic and community agencies to facilitate the exchange of clinical
and referral information.
stratification tools and ongoing assessments including ED utilization and
hospitalizations to address the medical/psychosocial/financial needs of
patients and their support systems in both hospital and ambulatory settings.
patients and support systems in order to enhance patient and support system
engagement.
communication as needed.
care.
Social Services Care Manager.
ancillary clinical services to meet the needs of hospital, clinic and regional
customers.
patients and their support systems.
the Social Services Care Manager to guide/advocate placement to the appropriate
Acute rehab, LTACH, SNF, long-term care facility, assisted living facility, or
Home Health Care, in-home services, hospice, ancillary OP services and/or DME
as clinically appropriate.
Manager.
patient care.
Insurance and Utilization Management
readmission penalties.
benefits.
Evaluation
makes recommendations to the multidisciplinary/healthcare team when indicated.
Modifies the plan of care/goals to reflect changes in patient or their support
system status and needs.
related to plan of care.
Documentation
Electronic Medical Record per program guidelines.
documentation and communication consistent with organization/department policy
as well as the Board of Nursing and ethical guidelines established and
universally supported by the nursing profession.
and maintained in accordance with Billings Clinic policy, HIPPA, state and
federal guidelines.
Safety/Quality Assurance/Risk Management
planning, work teams and process improvement activities
addressing confidentiality, infection control, patient rights, medical ethics,
advance directives, disaster protocols and safety.
addressing confidentiality, infection control, patient rights, medical ethics,
advance directives, disaster protocols and safety.
policies/processes relevant to job performance.
communication with patients, support systems and colleagues consistent with the
Board of Nursing and ethical guidelines established and universally supported
by the nursing profession.
meet the needs of the department/organization.
Outpatient Care Management Specific
(Primary Care, SDC, specialty office, ancillary departments). Coordinates
services for medical and non-medical care coordination needs that are episodic
or longitudinal.
to home, SNF to home/assisted living, or alternate setting per program
guidelines.
longitudinal education and support.
and Social Service Care Managers to address the needs of shared patients.
Utilizing shared knowledge to address complex patient needs.
to advance the role of Outpatient Care Management, strengthen partnerships and
meet department and patient needs.
