RN Care Manager - Pop Health-UNCPN Care Management
Company: UNC Health Care
Location: Raleigh
Posted on: January 14, 2021
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Job Description:
Job DescriptionDescription Become part of an inclusive
organization with over 30,000 diverse employees, whose mission is
to improve the health and well-being of the unique communities we
serve. Summary: The purpose of this position is to provide ongoing
support and expertise through comprehensive assessment, planning,
implementation and overall evaluation of individual patient needs.
The overall goal of the position is to enhance the quality of
patient management and satisfaction, to promote continuity of care
and cost effectiveness through the integrating and functions of
case management, utilization review and discharge planning. The
Care Manager must be highly organized professional with great
attention to detail, adaptable to frequent change, and compliant
with regulatory and departmental guidelines and policies. This
position will be stationed in three (3) UNC Family Medicine
practices: North Raleigh, West Raleigh, and White Oak.
Responsibilities: 1. Identify Cases & Prioritize Day - Review work
list to prioritize patients and identify new admissions. Conduct
and document assessment and a plan of care in Epic--- per
departmental guidelines. Participate in Daily Care Management
Touchpoint per established protocols. Consult to SW per established
criteria. If indicated, communicate with Care Management Assistant
(CMA) to share priorities. 2. CAPP Meeting - Attend and actively
participate in CAPP meetings for assigned units to provide and
receive information on patients' progression. Alert care team to
concerns that could impact anticipated discharge of the patient and
any care that will assist with discharge readiness. Modify
discharge plan based on information shared at the meeting. Assist
with identification of the expected discharge date (EDD). Complete
follow-up from CAPP as appropriate. As necessary meet with the
Utilization Manager (UM) and SW after the meeting to discuss
updates and action items. 3. Complex Care Meeting - Attend weekly
Complex Care Meeting (CCM). Present on patients during CCM and
collaborate to problem solve issues with complex patients and
identify trends. Formulate potential solutions with Utilization
Manager and Social Worker and continuously monitor cases/follow up
on all action items. Proactively identify high risk cases that need
to be escalated to the list that are not scheduled for discussion
that week. Complete CCM follow-up after the meeting as assigned. 4.
Active Consults - Discuss with appropriate members of the
multidisciplinary team when there are barriers to discharge and
psychosocial concerns impacting progression of care or readmission
risk. Coordinate family meetings, as necessary, to support the
progression of care. Provide education on community resources,
support/educational groups, and any other appropriate resources to
patient, family, and care team. Educate and/or coordinate referrals
to community resources and post-acute providers as necessary. 5.
Care Progression and Transition Planning - Communicate medical
milestones for transition with the patient/family. Identify
patients with barriers to discharge based on experience,
Communication and Patient Planning (CAPP) Meetings and/or Complex
Care Meeting (CCM). Monitor all observation patients throughout the
day to ensure appropriate progression of care. Identify patient's
readiness to discharge based on discussions with the
patient/family/care team on an ongoing basis. Assess the discharge
plan to determine needs post-discharge and communicate to
patient/family/care team on an ongoing basis. Identify required
authorization for post-discharge services and refer to the
appropriate post-discharge service provider. Participate in
medication resource management for non-resourced patients, as
needed. Verify patient's understanding/agreement of discharge plan.
Refer administrative tasks (e.g., faxing, form processing) to Care
Management Assistant. Consult Social Worker and/or Utilization
Manager per established departmental protocol. Maintain knowledge
of patient needs and concerns through scheduled touch points and
review of documentation . Escalate urgent or complex cases to
appropriate Care Management leadership according to established
departmental escalation process. 6. Professionalism - Demonstrates
flexibility and professionalism in a dynamic environment with
frequent re-ordering of priorities and assignments. Uses critical
thinking skills to evaluate and prioritize rapidly changing
demands, working collaboratively to best accomplish the team's
mission. 7. Documentation - Documents activities, events, and
information per standards in established software systems in a
timely, accurate, and complete manner. Identifies Avoidable Delays
and documents causes for delay consistent with department
standards. 8. Confidentiality - Uses established policies and
processes to handle, discuss, and transmit protected health
information in manner consistent with privacy and compliance
expectations and policies. 9. Compliance and Performance
Keywords: UNC Health Care, Raleigh , RN Care Manager - Pop Health-UNCPN Care Management, Executive , Raleigh, North Carolina
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