Care Management Nurses (11058)

Northern Light Health
Job Description

Northern Light Eastern Maine Medical Center

Department: Care Management

Position is located: Northern Light Eastern Maine Medical Center

Work Type: Full Time \ 8:00 AM to 4:30 PM

To Apply Click: Care Management Nurse 

For More Information: TEXT "Care Mgmt" to (207) 506-0033

Oversee clinical care to patients with complex care needs, chronic disease and through transitions of care. Serves in an expanded nursing role to collaborate with the Medical Team to provide a model of care that ensures the delivery of quality, efficient, and cost effective healthcare services. Integrates evidence based clinical guidelines, preventive guidelines, protocols, and other metrics in the development of treatment plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare. Reports to: Regional Manager, Care Coordination for Beacon Health, LLC.

• Is a complementary member of the health care team
• Collaborates with members of the health care team and the patient/family
• Plans the coordination of services required, considering the unique needs of the patient/family (cultural, religious, age-specific, etc.) to achieve desired outcomes.
• Communicates plan of care, including changes and issues related to plan of care promotes collaboration among all members of the healthcare team.
• Effectively facilitates communication between the physician and others in order to achieve established goals for the patient/family.
• Exhibits excellent interpersonal communication skills.
• Appropriately communicates necessary information to the Manager of Care Management.
• Develops and maintains rapport and working relationships with patients and family members as evidence by Avatar patient satisfaction scores.
• Provides patient advocacy by ensuring that the pt/family are actively involved or represented in planning for care.
• Is a resource to staff and physicians regarding appropriateness of admission and continued stay and levels of care (including related documentation requirements
• Effectively and appropriately channels pertinent information between the patient/family and other caregivers, including the physician and insurance companies.
• Negotiates with members of the health care team and the patient/family, to ensure that established goals are mutually acceptable.
• Recognizes the unique contributions of all members of the health care team and appropriately calls upon these expert resources to achieve desired outcomes for assigned caseload.
• Refers to Manager of Care Management on complex situations that may require referral to social work referral center.
• Demonstrates the ability to organize and carry out duties without direct supervision
• Performs admission review. Admission assessments are holistic and address physical/psychosocial/health/environment/support systems/educational needs and financial resources.
• Collaborates with the Physician, and other members of the health care team to implement the plan of care in a maximally efficient and effective manner.
• Accurately evaluates the progress of the patient/family on a daily basis and with the health care team, modifies plans in order to achieve established goals.
• When possible, begins the process of care coordination prior to admission (i.e. elective surgeries)
• Effectively collaborates with appropriate charge nurse and or primary nurse to ensure desired pt. outcomes are achieved.
• Develops and maintains a process for effective, timely and ongoing communication with his/her assigned Team Leader, charge nurse, care management assistants, denial specialist and physicians, and other members of the health care team.
• Makes arrangements to ensure all services and supplies required by the patient post-discharge will be available.
• Coordinates patient transfer to the appropriate level of care, communicates resulting decision to pt/family, and members of the healthcare team.
• Provides responsibility for his/her caseload on unit (s) or disease-specific patients to ensure
• Services are well coordinated, appropriate and timely, documented in 3M and documentation of pt/responsible party's preference of provider in medical record.
• Facilitates communication regarding the plan of care
• Resources are appropriately expended.
• Suitable and timely continuing care plans are implemented.
• An effective liaison relationship exists between physicians, EMMC staff, and community agencies.
• Appropriately refers to EMMC/EMH and community resources.
• Coordinates the interdisciplinary care plan of an assigned patient caseload throughout the episode of illness
• Works to achieve optimal health, resource and satisfaction outcomes.
• Reviews and assesses the episodic plan of care on an on-going basis
• Identifies additional objectives, goals and actions based on assessed needs and desired patient outcomes.
• Successfully and creatively uses negotiation skills to obtain the resources necessary to meet the established goals for a patient.
• Demonstrates understanding of care management philosophy and principles through application of problem solving techniques and critical thinking skills to facilitate positive outcomes
• Recognizes and is able to comfortably address conflict that is an obstacle to a patient receiving coordinated care.
• Constructively participates in Eastern Maine Medical Center committees, as appropriate.
• Attends unit staff meetings.
• Ensures that the patient/family's understand the d/c plan, and that the educational needs regarding d/c plan have been met.
• Demonstrates understanding and working knowledge of resources available and of how to access available resources to meet patient’s needs
• Possess the ability to stay focused on the desired outcomes, without getting sidetracked by tasks or activities that are not contributing to keeping/getting a patient on track.
• Completes annual I Care training per EMMC policy.
• Recognizes and acts on opportunities to educate staff regarding payer systems, reimbursement mechanisms and levels of care.
• Expedites the scheduling of tests and procedures as required to move patients through the system in a fiscally responsible way.
• Recognizes and intervenes when either over or under utilization of services is identified.

Other information:
BLS Required.  

Competencies and skills:
* Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.
* Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation.
* Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.
* Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.

* Registered Nurse

* Bachelor's Degree

Working conditions:

* Potential exposure to abusive and/or aggressive people.
* Work with computers, typing, reading or writing.
* Potential exposure to diseases or infections.
* Need to drive to perform responsible duties.
* Potential exposure to hazardous materials.
* Lifting, moving and loading 20 to 30 pounds.
* Potential exposure to noise levels being uncomfortable.
* Continuous sitting.
* Potential exposure to noxious odors.
* Continuous standing.
* Potential exposure to very hot or cold temperatures.
* Continuous walking.

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