Care Manager, RN

Summary / Objective:

The Care Manager, RN acts in a non-caregiver capacity by facilitating coordination and communication between all members of the health care team in the decision making process to minimize fragmentation of the health care delivery system. As a member of the Care Management Department, this position is responsible for contributing to the standards of quality and service expected by both external and internal stakeholders, including ensuring accurate information flows to interdepartmental teams, proper documentation and adherence to standards related to case management activities.

Essential Functions:

• Provides Transitional Care Management (TCM) services and Care Management (CM) services according to the PSW written guidelines, NCQA standards, and general standards of nursing practice.
• Documents in the population health tool summary of interactions and services provided to support client outcomes for both TCM and CM services.
• Assesses patients for care management services after a referral has been made based on the admission screening and referrals for potential patient issues.
• Coordinates with Utilization nurse to direct care to the appropriate care setting to promote best patient outcomes and efficient use of healthcare resources.
• Assesses member’s physical, psychological and discharge planning needs through communication with appropriate care providers to coordinate care accordingly.
• Identifies, assesses and manages clients receiving services per established criteria.
• Coordinates care management activities with public agencies, social workers, hospital/nursing facility discharge planner, ancillary service providers and other providers as needed.
• Assess need to involve medical director or primary care team when appropriate to assist with development of client directed plan of care.
• Regularly reviews and updates care plans for continuity of care and facilitates plan modifications including barriers to goals.
• Coordinates with Non-Licensed Care Navigators to ensure appropriate follow-up with high risk members to address identified goals and barriers.
• Documents all interventions and telephone encounters with providers, clients and vendors in accordance with established documentation standards.
• Prepares and provides reports to Manager, other departments, and outside agencies as needed.
• Continues own education by keeping his/her knowledge current and conducts independent research of Medicare guidelines to strengthen general understanding of state and federal resources to support position responsibilities.
• Ensures compliance with departmental and PSW policies and procedures, with special emphasis on compliance with HIPAA privacy and security requirements and all state, federal and plan regulatory mandates.