[Hiring] Nurse, Individualized Care Nurse Care Manager @Cardinal Health

Role Description

The Nurse, Individualized Care Nurse Care Management provides a structured patient-centered healthcare service by coordinating medical treatments, delivering patient education and bridging the gap between patients, healthcare providers and support systems to promote continuity of care.

Responsibilities

• Collaborate with health care staff responsible for patient care to develop, implement, monitor and evaluate appropriate clinical care or other services to meet the needs of patients and coordinate all activities related to care management.
• Strong working knowledge and basic medical management of chronic disease states, like cancer.
• Ensures that areas of responsibility are operating in compliance, including documentation and records with all federal, state, and regulatory agencies.
• Document all encounters and activities in the designated system accurately and in a timely manner.
• Participate in interdisciplinary case conferences and team huddles to ensure coordinated care as needed.
• With the oncology care team and internal care management team, identifies patients to be case managed, assesses patient’s care requirements, modifies or coordinates modification of patient care and intervenes, as necessary.
• Coordinates in the development and review of clinical pathway trends and shares with appropriate service and management teams.
• Assist in quality improvement activities by identifying trends, barriers, and opportunities to improve program outcomes.
• Attends meetings, seminars, and conferences as appropriate.

Principal and Chronic Care Management

• Obtain member consent before enrolling them into the Care Management program and beginning outreach activities.
• Telephonically manage patient care, through the following methods:
• Review of the patient’s medical, functional, and psychosocial needs.
• Medication reconciliation with review for adherence.
• Reinforce disease self-management education and symptom management.
• Communicate oncology provider instructions and advice, and provide patient education materials.
• Referral to and coordination with community service organizations and make and/or specialist appointments and schedule other tests, treatments or procedures as needed.
• Facilitating patient follow-up visits with acute or chronic needs.
• Documents all concerns and follow-up and escalates to the onsite Clinical Team, or oncology provider when appropriate.
• Provide coaching and health promotion to encourage self-management and adherence to care plans.
• Manage a caseload size ranging between 100-150 members, and assist with other programs as needed.
• Collaborate with onsite clinical staff to order supplies for patients as needed (e.g., blood pressure machines, remote patient monitoring medical supplies).
• Track and report on member progress, escalating complex cases to provider, the onsite clinical team or program leadership as needed.

Transitional Care Management

• Attempt outreach to TCM members on the caseload via phone call as needed to support onsite TCM programs.
• Assist with discharge planning: assess needs; help coordinate medication reconciliation; schedule TCM (Post-Acute) face-to-face visit with provider.
• Triage patient needs and identify necessary plan of action within such as scheduling an appointment, triaging for a provider or directing the patient to the ER, etc. as needed.
• Bridge gaps between the onsite clinical team and the community, and ensuring patients fully understand their discharge instructions and follow-up care.
• Ability to collaborate effectively with the onsite clinical team/staff and remote care management team to support discharge planning, care transitions and ongoing care coordination interventions.

Qualifications

• Registered Nurse with a current, unrestricted California license.
• 5 years’ experience-hospital or clinical, involving patients with complex chronic disease states preferred.
• Care Management experience is strongly preferred.
• Oncology patient experience is strongly preferred.
• Experience with Microsoft Office products.
• Superior communication skills to include verbal and written.
• Must be able to work collaboratively; team focused.
• Excellent organizational skills.
• Bilingual skills a plus.

Requirements

• Ability to identify problems and recommend solutions.
• Ability to work independently with minimal supervision.
• Commitment to improving health equity and supporting vulnerable populations.
• Meets regularly with management team to discuss feedback from call monitoring and quality reviews. Discusses progress on productivity and quality goals.
• Responsible for maintaining HIPAA guidelines.

Benefits

• Medical, dental and vision coverage.
• Paid time off plan.
• Health savings account (HSA).
• 401k savings plan.
• Access to wages before pay day with myFlexPay.
• Flexible spending accounts (FSAs).
• Short- and long-term disability coverage.
• Work-Life resources.
• Paid parental leave.
• Healthy lifestyle programs.