Reference #: 1009049
SHIFT:Any (United States of America)Seeking Breakthrough MakersChildren's Hospital of Philadelphia (CHOP) offers countless ways to change lives. Our diverse community of more than 20,000 Breakthrough Makers will inspire you to pursue passions, develop expertise, and drive innovation.At CHOP, your experience is valued; your voice is heard; and your contributions make a difference for patients and families. Join us as we build on our promise to advance pediatric care-and your career.CHOP's Commitment to Diversity, Equity, and InclusionCHOP is committed to building an inclusive culture where employees feel a sense of belonging, connection, and community within their workplace. We are a team dedicated to fostering an environment that allows for all to be their authentic selves. We are focused on attracting, cultivating, and retaining diverse talent who can help us deliver on our mission to be a world leader in the advancement of healthcare for children.We strongly encourage all candidates of diverse backgrounds and lived experiences to apply.A Brief Overview
This Care Manager position s located out of CHOP Main Hospital. It is 40 hours a week and is a hybrid role. It requires onsite clinic days Mon, Wed am and Thursdays.
RN with 5 years previous RN work expereince is required. This team is looking for a candidate who has expereince with Adolescents and Adults with Developmental Disabilities and complex management.
The Registered Nurse (RN) Care Management Coordinator or "Care Manager" provides care management services to a panel of medically complex patients or populations of patients who have risk factors that are amenable to care management interventions. The RN Care Manager may be assigned regionally to support one or more CHOP primary care practices, may be assigned to the care of patients who receive primary care outside of the CHOP Care Network, or a specialty care disease-specific Care Management model. S/he serves as an advocate for patients and their families and assists them to navigate the health care system. The RN Care Manager facilitates the continuity of a patient's care by functioning as a liaison between primary care providers (PCPs), outpatient specialty care providers and inpatient care teams, as well as payers, medical equipment suppliers, home care providers, subacute and chronic care facilities, and community resources. S/he collaborates with ambulatory, emergency department and inpatient care teams with the goals of optimizing communication among care providers, promoting seamless transitions between care settings and facilitating the appropriate use of health care resources.What you will do
Practice
General care management responsibilities:
Identify patients in need of care management and maintain a patient database.
Provide care management services to an assigned panel or designated population of patients and their families.
Develop and maintain patient-centered, intra-disciplinary, longitudinal plans of care and monitor patients' progress toward care plan goals.
Advocate for patients and families and promote communication and collaboration to keep all care team care members informed of patients' care needs and to ensure that patients access and benefit maximally from available health care resources.
Facilitate transitions across care settings.
Assist patients and families with access to health care services as needed, including collaboration with payers.
Teach, coach and counsel patients and their families to build independence and skills for self-management.
Monitor and evaluate patients' outcomes and communicate outcomes to health care teams.
Use information systems to document and track care management interventions
Transfer patients to higher or lower levels of care management support as appropriate.
Collaborates with patient and family health care providers and agencies using a multidisciplinary and holistic approach to help the p tient and family set realistic and achievable goals to achieve the desired outcomes.
Utilizes professional and community knowledge and influence to obtain resources in the most cost-effective manner to best meet the patient's developmental, physical, psychosocial and financial needs.
Researches, selects and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes.
Adapts behavior as needed to the specific patient population, including but not limited to respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style.
Outpatient care management responsibilities:
Communicate regularly with PCP and relevant specialists regarding acute and chronic patient care issues and intra-disciplinary care plans.
Review medical records prior to encounters and participate in outpatient visits as necessary to assist in the development and updating of care plans.
Participate in care team meetings to discuss active clinical issues and progress toward goals.
Establish routine communication plans and communicate regularly with patients and families to assess ongoing care needs and to facilitate proactive care planning, including regular telephone contact.
Serve as a liaison with insurers/payers, review resource utilization and eligibility and identify the need for and facilitate obtaining additional health insurance services.
Complete letters of medical necessity, referrals and prior authorizations as needed.
Collaborate with home nursing companies and Durable Medical Equipment (DME) providers.
Identify and develop relationships with community resources to support patient's needs and makes referrals when appropriate.
Inpatient care management responsibilities:
Respond to referrals from inpatient teams, primary care providers or referring hospitals/facilities prior to discharge, and provide consultation on enrollment in longitudinal care management services.
Establish relationships with patients who are newly enrolled in care management services prior to discharge and collaborate with the inpatient teams regarding discharge plans and anticipated outpatient care needs.
Serve as a longitudinal resource for inpatient teams to obtain relevant information and updates about patients during admissions, and collaborate with inpatient teams regarding outpatient care needs and discharge plans.
Facilitate scheduling post-discharge follow up telephone encounters and visits with the PCPs and specialists.
Coordinate plans for follow up visits with care providers and for laboratory and diagnostic studies after discharge.
Attend inpatient family meetings and care conferences when necessary to integrate inpatient care with patients' longitudinal, intra-disciplinary care plans.
Emergency Department care management responsibilities.
Serve as a resource to Emergency Department providers for information about patients that will inform the Emergency Department plan of care.
General registered nursing duties (including but not limited to);
Obtain and document patients' histories.
Perform and document physical assessments.
Conduct telephone triage and refer patients to appropriate services.
Perform and/or interpret basic laboratory tests.
Professionalism and Leadership
Assist with surveys and other data collection activities to measure the effectiveness of care management interventions.
Support strategies and changes as needed to improve the care management program.
Serve as an institutional expert on care coordina
