Nurse Care Manager - RN/LPN/LMSW Full-time Job

Job Definition:

The Care Manager position is responsible to help support and enhance patient-centered care and service within the guidelines of the care management model. These tasks are provided so that patients are able to achieve positive outcomes and maintain an optimal level of wellness by collaborating with the interdisciplinary team.

Scope of Position:

The person in this position may be asked to perform care coordination for all ages from Newborns to Geriatrics. Responsibilities will be conducted on a variety of sites (including but not limited to clinics, hospitals, patient homes or telephonically). Each person needs to be knowledgeable and perform the expectations in areas assigned in care delivery.

Patient & Family:

Provides assistance in a collaborative manner for the delivery of care that optimizes the quality and efficient use of resources. Support activities will address medical, economic, social, psychological, and care gaps.

Work with patients and families, providers, facilities and employers for safe transition plans as needs are assessed. Follows all confidentiality regulations including HIPAA.

Completes assigned duties efficiently within specified timelines (example documentation in specific systems completed by the end of the day on date of service)

Proactive patient assessment/coordination.

Assist in coordination and referral to appropriate healthcare and community resources.

Coordination with PCP office and specialists related to transition management for chronic disease processes and to improve the delivery of appropriate level of care

Utilize patient database information to coordinate interventions for chronic disease, transition and preventive needs

Use principles of motivational interviewing to engage members, assesses readiness to change, and implement interventions.

Ability to conduct assessments/provide assistance in a variety of settings: inpatient/outpatient, on-site or telephonically

Medical Services Staff & Providers:

Communicates with the medical office team/ provider of pertinent patient information in order to achieve outcomes.

Communicate necessary elements between patients and families in conjunction with physician's goals and plans for continuum of care.

Communicates results effectively.

Serves as a role model to team members regarding the development of strategies, quality initiatives, compliance issues, etc

Attends interdisciplinary conferences, when available

Operations:

Completes patient visit documentation as required. (ie: authorizations, logs, care plans)

Provides necessary administrative/ clerical support, completes administrative assignments related to care management in a timely manner and meet all designated deadlines.

Tracks results in databases for reporting. Collects, tracks, enters data

Understands compliance to meet CMS (centers of medicaid services) regulations, where needed and as applicable

Promote team growth and success with a unified approach to the work environment, positive attitude and ability to facilitate change. Able to function well on a team and individually

Personal Growth and Development

Participate in personal and professional activities, education, and work-related experiences, to improve performance

Identifies personal growth needs.

Sets personal growth and development goals.

Maintains license or certification.

Attends educational offerings. 20 hrs a year.

All other duties as assigned.

Ballad Health is an integrated healthcare system serving 29 counties of Northeast Tennessee, Southwest Virginia, Northwest North Carolina and Southeast Kentucky. Our system includes 21 hospitals, a dedicated children's hospital, rehabilitation and behavioral health facilities, outpatient centers and a comprehensive medical group. At Ballad Health, we are committed to fulfilling our mission to improve the health of the people we serve.