Care Manager, RN

Company Description

CareAbout Health is a managed services organization (MSO) that provides expert advice, resources, tools, and other support to its portfolio of medical groups and healthcare focused companies. CareAbout Health is helping align incentives to create a world where patients, providers, and payers work together in a seamless, coordinated manner toward common goals : higher quality, lower cost, better outcomes.

Role Summary and Responsibilities :

The Care Manager, RN (CM-RN) will work on a multidisciplinary healthcare team in a primary care setting, focusing on coaching and coordination of care for patients needing navigation and follow up. The CM-RN will identify the needs of complex members and assist with the practice to develop processes for managing the high-risk member population. This person will promote patient-centered care, working with primary care providers and medical home team members. The CM-RN plays a key role in the transformation of the medical practice participating in VBC / APM contracts.

• Develop constructive relationships with local hospitals admission offices, case managers and discharge planners.
• Work to develop systems, processes, and initiatives to engage these entities in relevant case management activities with high-risk members of the practice ensuring necessary post discharge needs are met.
• Monitor to ensure care is coordinated with home care agencies, specialists, or other resources needed.
• Monitor to make sure follow-up primary care visits are obtained within 24 hours of hospital discharge.
• Conduct follow-up to ensure that initial patient assessment and post-visit consultation includes a comprehensive medical, psychosocial, and that functional assessment of the patient are all completed and in order as identified by the patient centered medical home.
• Communicate with and coach patients to ensure they are aware of discharge instructions, have necessary prescriptions, access to medications, and understand how to take the necessary medications, including what to look for regarding adverse events as per their care givers instructions.
• Monitor that appropriate home care, hospice care, and other ancillary services (DME, infusion services etc.) are in place and are being delivered as directed by the care team.
• Coordinate necessary referrals and authorizations within care management areas.
• Facilitate the information flow between hospital, long-term care, specialists and home health representatives and the care team.
• Work with physicians and office staff to help identify high risk, high need, and potentially high-cost patients.
• Assist physicians and care team in implementing processes for best practices for preventive services, chronic care, and disease management.
• Work collaboratively with physicians and the care team to ensure patient adherence to medical plan of care, including all appropriate preventive and disease-specific screenings, interventions, treatment goals – including self-management goals, and contract schedules.
• Coordinate care and communicate with multiple providers, both within and external to the practice.
• Identify and utilize cultural and community resources.
• Verify that practice has necessary behavioral health screening tools (depression / substance abuse), and all members are receiving appropriate screening and behavioral health interventions.
• Facilitate any necessary follow-up behavioral health needs with local behavioral health providers.
• Attend required training and collaboration sessions [i.e., learning sessions, care management meetings, and practice team meetings] as scheduled.
• Assess patient needs and develop a plan of action to address needs in collaboration with the primary care physician.
• Provide and facilitate open communication, regarding patient status, with physicians and office staff.
• Obtain records from other physicians / labs / diagnostic centers as requested by the physicians and as needed for care coordination efforts.

Qualifications