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RN Care Manager Marysville - The Everett Clinic - Marysville Washington
Company: Optum Location: Marysville, Washington
Posted On: 04/25/2024
$7,500 Sign on Bonus for External Candidates For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together. Under minimal supervision, responsible for ensuring the continuity of care in the outpatient setting utilizing the appropriate resources within the parameters of established contracts and patients' health plan benefits. Facilitates continuum of patients' care utilizing advanced nursing knowledge, experience, and skills to ensure appropriate utilization of resources and patient quality outcomes. Performs care management functions on-site and telephonically as the need arises. Works in conjunction with the care team and PCP as care team leader to develop a patient centered plan of care. Primary Responsibilities: - Prioritizes patient care needs upon initial visit and addresses emerging issues
- Meets with patients, patients' family and caregivers as needed to discuss care and treatment plan
- Identifies and assists with the follow-up of high-risk patients in acute care settings, skilled nursing facilities, custodial and ambulatory settings
- Consults with physician and other team members to ensure that care plan is successfully implemented
- Coordinates treatment plans with the care team and triages interventions appropriate to the skill set of the team members. Uses protocols and pathways in line with established disease management and care management programs in order to optimize clinical outcomes and minimize unnecessary institutional care
- Monitors and coaches patients using techniques of motivational interviewing and behavioral change to maximize self-management
- Oversees provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc. in order to maintain continuity of care
- Works in coordination with the care team and demonstrates accountability with patient management and outcome
- Discusses Durable Power of Attorney (DPOA) and advanced directive status with patient and PCP when applicable
- Maintains effective communication with the physicians, hospitalists, extended care facilities, patients, and families
- Provides accurate information to patients and families regarding resources available to them through health plan benefits, community resources, and referrals
- Participates actively in Monthly Care Management Department meetings and daily huddles
- Documents pertinent patient information and Care Management Plan in Electronic Health Record
- Coordinates care with central departments on assigned patient caseload, including, inpatient, long term care facilities, adult family homes, and home health agencies
- Demonstrates a thorough understanding of the cost consequences resulting from Care Management decisions through utilization reports and systems such as Health Plan Benefits, CM dashboards and reports
- Maintains concise and accurate documentation that supports effective and efficient management of care plans to decrease Emergency and hospital readmissions You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications: - Graduation from an accredited school of nursing
- Washington State Registered Nurse license
- Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross)
- 3+ years of experience in a clinical setting
- Washington State driver's license and vehicle for work-related travel
Preferred Qualifications: |
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