Under the direction of department leadership, the Care Manager provides services consisting of comprehensive care management, care coordination and care continuing care services. The Care Manager is accountable for a designated patient caseload/population and plans effectively in order to meet patient needs. The Care Manager is a support to providers and the multidisciplinary in facilitating patient care. The Care Manager strives to enhance the quality of clinical outcomes and patient satisfaction while managing the cost of care.

Essential Job Functions

ASSESSMENT

• Conducts initial and ongoing assessments and chart reviews of each assigned patient to identify potential and or actual barriers and care needs.
• Proactively screens and assesses the acuity and transitional needs of each assigned patient.
• Engages and collaborates with patients, support systems and the multidisciplinary/healthcare team to establish a plan of care that addresses the mutually identified needs of the patient.

INTERVENTION AND CARE COORDINATION

• Demonstrates the ability to interpret clinical information and understand health care treatment and systems.
• Supports patients to ensure they can function to the best of their ability and maintain optimal health related to their medical condition(s). Identifies and addresses gaps in knowledge/understanding/education related to disease management.
• Participates in the patient’s plan of care by interacting/collaborating with patients, support systems, healthcare professionals and community and state agencies. Serves as a liaison between hospital, clinic and community agencies to facilitate the exchange of clinical and referral information.
• Identifies high-risk patients through risk stratification tools and ongoing assessments including ED utilization and hospitalizations to address the medical/psychosocial/financial needs of patients and their support systems in both hospital and ambulatory settings.
• Reinforces goals of care and treatment plans with patients and support systems in order to enhance patient and support system engagement.
• Coordinates care conferences to support effective communication as needed.
• Helps navigate the patient throughout the continuum of care.
• Effectively collaborates and coordinates care with the Social Services Care Manager.
• Maintains current knowledge of community resources and ancillary clinical services to meet the needs of hospital, clinic and regional customers.
• Provides information about available resources to patients and their support systems.
• Partners with the multidisciplinary/healthcare team and the Social Services Care Manager to guide/advocate placement to the appropriate Acute rehab, LTACH, SNF, long-term care facility, assisted living facility, or Home Health Care, in-home services, hospice, ancillary OP services and/or DME as clinically appropriate.
• Acts as a clinical resource to the Social Services Care Manager.
• Understands consultative disciplines and their role in patient care.
• Maintains respectful and professional communication skills.

INSURANCE AND UTILIZATION MANAGEMENT

• Maintains working knowledge of CMS requirements and readmission penalties.
• Maintains working knowledge of insurance/payer benefits.
• Evaluation
• Monitors the need for revisions in the plan of care and makes recommendations to the multidisciplinary/healthcare team when indicated. Modifies the plan of care/goals to reflect changes in patient or their support system status and needs.
• Monitors, evaluates and documents patient progress related to plan of care.

DOCUMENTATION

• Documents accurately and in a timely manner in the Electronic Medical Record per program guidelines.
• Utilizes standards of professional practice in all documentation and communication consistent with organization/department policy as well as the Board of Nursing and ethical guidelines established and universally supported by the nursing profession.
• Documentation and patient information shall be secured and maintained in accordance with Billings Clinic policy, HIPPA, state and federal guidelines.

SAFETY/QUALITY ASSURANCE/RISK MANAGEMENNT

• Identifies service gaps and participates in hospital and department programs to address and improve quality of care.
• Advocates for marginalized or vulnerable populations by identifying cases of abuse and neglect and appropriately involving risk management and regulatory agencies.

PROFESSIONAL ACCOUNTABILITIES

• Participates in continuing education, department planning, work teams and process improvement activities.
• Maintains current Licensure.
• Adheres to department and organizational policies addressing confidentiality, infection control, patient rights, medical ethics, advance directives, disaster protocols and safety.
• Demonstrates the ability to be flexible, open minded and adaptable to change.
• Maintains competency in organizational and departmental policies/processes relevant to job performance.
• Utilizes standards of professional practice in all communication with patients, support systems and colleagues consistent with the Board of Nursing and ethical guidelines established and universally supported by the nursing profession.

INPATIENT CARE MANAGEMENT SPECIFIC

• Collaborates with post-acute services, Ambulatory Care Managers and PCP’s to ensure successful transition back to the home environment. Makes appropriate Ambulatory Care Management referrals. Anticipates those patients who may require more support after hospital discharge and communicates these concerns.
• Utilizes length of hospital stay, past utilization of resources and risk stratification to identify patients at high risk for readmission.
• Interfaces effectively with the Utilization Review department to stay current on patient’s eligibility for admission, continuing stay, or readiness for discharge.
• Communicates with medical staff, coordination team and nursing staff regarding appropriateness of admission, need for continued stay and discharge plans.
• Identifies and records episodes of avoidable days.
• Evaluates the appropriateness of care delivery in the inpatient setting and communicates any discrepancies with the medical team.
• In addition to the above Care Managers in the Emergency Department will also be responsible for the following duties:
• Screens ED admissions using established criteria for specific payer populations.
• Understands insurance/payer policy language, benefits and authorization requirements for admission.
• Discuss payor criteria and issues on a case-by-case basis with clinical staff.
• Ensures that the patient is in the appropriate “status” and level of care for the clinical condition. Utilizing screening criteria and physician advisor, per department standards.

OUTPATIENT CARE MANAGEMENT SPECIFIC

• Receives referrals on patients being seen in the clinic (Primary Care, SDC, specialty office, ancillary departments). Coordinates services for medical and non-medical care coordination needs that are episodic or longitudinal.
• Receives referrals for elective procedure patients who would benefit from pre-discharge planning assessments and resource coordination.
• Assists patients through care transitions from hospital to home, SNF to home/assisted living, or alternate setting per program guidelines.
• Manages a panel of high-risk patients that require longitudinal education and support.
• Effectively collaborates with Inpatient Care Managers and Social Service Care Managers to address the needs of shared patients.
• Able to function effectively as a part of a team. Utilizing shared knowledge to address complex patient needs.
• Supports Billings Clinic and community-based programs to advance the role of Outpatient Care Management, strengthen partnerships and meet department and patient needs.

• Supports and models behaviors consistent with Billings Clinic’s mission, vision, values, code of business conduct and service expectations. Meets all mandatory organizational and departmental requirements. Maintains competency in all organizational, departmental and outside agency standards as it relates to the environment, employee, patient safety or job performance.

• Performs all other duties as assigned or as needed to meet the needs of the department/organization.

Minimum Qualifications

Education

• Four (4) year / Bachelor of Science degree in Nursing (BSN) or Bachelor of Arts in Nursing (BAN) preferred

Experience

• Five (5) years of professional nursing in a related cardiac care area such as critical care, ambulatory telemetry unit, or emergency services

Certifications and Licenses

• National Institutes of Health Stroke Scale (NIHSS) certification required or to be obtained within first year of employment - Within 1 year of hire
• Current Registered Nurse license in the state of Montana - At hire