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Northern Light Maine Coast Hospital

Department: Care Management

Position is located: Northern Light Maine Coast Hospital

Work Type: Full Time

Hours Per Week: 30 Hours per Week

Work Schedule: 7:00 AM to 4:00 PM

Summary:

This position is responsible for providing care management and discharge planning for Maine Coast & Blue Hill Hospitals. Assumes a leadership role with the interdisciplinary team to achieve optimal clinical and resource outcomes including supervision of care managers, social workers, and swing coordinators. Liaison with referring hospitals to consider transfers. Manages utilization and quality metrics. Coordinates care to minimize the fragmentation of healthcare delivery systems. Serves as a resource to nursing care units. Able to provide age-appropriate nursing care. Must be adaptable to a fast paced, ever-changing environment and be a strong team player.

Responsibilities:

+ Collaborates with providers and practice staff in identifying appropriate patients for care management utilizing established care management criteria. Assess, plans, implements and evaluates the needs of patients for discharge planning and care management. Performs initial and periodic holistic assessments for care management population. Prioritizes patients according to intensity, need, and required follow up

+ Formulates and implements a care management plan in collaboration with member organizations that addresses the patient’s identified needs by assessing patient/family issues, resources, and care goals. Determines options available to patients & educates patient/family on choices available. Establishes a care management plan that is mutually agreed upon by the health care team and the patient/family. Evaluates effectiveness of established plan and revises as needed.

+ Collaborates with providers & other healthcare team members including inpatient facilities, the patient’s payer, and health system administrators regarding transitions of care and facilitates care across the continuum to optimize clinical and financial outcomes. Determines & completes appropriate referrals. Serves as a liaison to providers, patients, & families for coordination of care services.

+ Maintains working knowledge of payer requirements. Develops collaborative working relationships with insurance case managers; negotiates on behalf of patient with third parties for cost-effective, high-quality services and to promote efficient use of resources

+ Initiates care conferences to discuss multidisciplinary team responsibilities, patient progress, new problems, etc. Identifies, facilitates, and effectively utilizes community resources to meet the identified needs of patients/families. Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence.

+ Maintains EMR databases on care managed population. Leads regular team meetings and peer review activities. Oversees orientation of new personnel. Precepts and mentors staff. Promotes collaborative teamwork. Develops relationships across broad organizational lines and where innovative and unstructured situations arise. Maintains quality metrics and leads department performance improvement projects.

+ Oversees and/or actively participates in departmental and organizational committees/meetings as applicable including but not limited to Long Length of Stay Meeting (LLOS), Readmission Committee, Multidisciplinary Rounds (MDRs), department staff meetings, & Quality and UR meetings. Reviews Discern reports and handles notifications.

Other Information:

BLS & ACLS 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 belonging, 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.

Credentials

+ Required Registered Nurse

Education

+ Required Associate's Degree

Working Conditions

+ Work with computers, typing, reading or writing.

+ Lifting, moving and loading 20 to 30 pounds.

+ Prolonged periods of sitting.

+ Prolonged periods of walking.

Coastal, Ellsworth, Maine, MCH, MCMH, Rural Health Care

Position Mgr- Care Management/RNLocation Req ID 84969