Care Manager Position Summary
This position may be eligible for a sign on incentive. 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 team 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
• Supports and models behaviors consistent with Billings Clinics 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.
• 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.
• Demonstrates the ability to interpret clinical information and understand healthcare treatment and systems.
• Supports patients to ensure they can function to the best of their ability and maintain optimal health related to their medical conditions. Identifies and addresses gaps in knowledge, understanding, education related to disease management.
Key Responsibilities
• Participates in the patients 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 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.
Collaboration and Communication
• 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.
• Maintains working knowledge of CMS requirements and readmission penalties.
• Maintains working knowledge of insurance, payer benefits.
Quality Improvement and Patient Safety
• 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 the plan of care.
• 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, departmental policy, as well as the Board of Nursing and ethical guidelines established and universally supported by the nursing profession.
Professional Development and Education
• 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.
• Participates in continuing education, department planning, work teams, and process improvement activities.
Certifications and Licenses
• Healthcare Provider and ACLS, CPR certifications.
• National Institutes of Health Stroke Scale (NIHSS) certification required or to be obtained within the first year of employment.
• Current Registered Nurse license in the state of Montana.
Education and Experience
• Minimum Qualifications: • 4-year Bachelor of Science in Nursing (BSN) or Bachelor of Arts in Nursing (BAN) preferred. • Five years of professional nursing experience, one within the Billings Clinic in a related cardiac care area such as critical care, ambulatory telemetry unit, or emergency services.
Additional Requirements
• Associate or Diploma RNs hired into this position must commit to completing their Bachelor of Nursing degree within 4 years of their date of hire. Billings Clinic will help support the cost through financial assistance.