RN Care Manager bei SoNE Health

The RN Care Manager (RN CM) is a Registered Nurse who works within the Care Management team to care manage a high-risk population with complex comorbidities such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes (Type I and II), renal diseases, including end-stage renal disease (ESRD) and chronic kidney disease (CKD). The RN Care Manager (RN CM) maintains patient-centered care working with patients and their families or caregivers in collaboration with their physicians and other health care team members, insurance providers, and community resources. The RN CM works within a multidisciplinary team approach toward the patient’s self-management of their conditions, creating and meeting actionable plan of care goals. Standards of practice include evidence-based disease management, care coordination, collaboration, leadership, accountability, advocacy, professionalism, and resource management.

This role is located at the company's headquarters in Windsor, CT, and operates in hybrid/remote environment.

Primary Responsibilities:

• Conducts a minimum of 10 telephone, telehealth or in-person patient engagements per day that includes a holistic nursing assessment, standardized screens, and education to patients identified on caseload assignment or as referred by member primary or specialty care providers.
• Guides patients through the health care system.
• Communicates with and assists patients in a professional and courteous manner.
• Coordinates transition of inpatient to outpatient care to decrease readmission rates.
• Coordinates continuity of patient care with stakeholders and other healthcare organizations as well as with primary and specialty care providers.
• Facilitates patient self-management of disease and behavior modification interventions creating SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) plan of care goals using Motivational Interviewing skills.
• Educates patients on prescribed medications, identifying and coordinating access and affordability, as well as other gaps in care.
• Practices cultural sensitivity and health equity toward improving health outcomes.
• Identifies and coordinates access to disease specific resources available for patients to enhance self-care management.
• Performs Social Determinants of Health (SDOH) screen to coordinate patient and caregiver access to community resources relevant to patient’s needs like housing, food security, medical transportation, or more.
• Coordinates preventive screen appointments and other gaps in care as identified.
• Monitors adherence to actionable care plans, evaluates effectiveness, and patient progress in a timely manner, facilitating revisions as needed.
• Complies with documentation requirements per programmatic workflows.
• Acts as a liaison between patients and their insurance providers to promote quality, cost-effective care with the best patient outcomes.
• Communicates nursing care plan to patient’s primary care provider, and other health team members as needed.
• Complies with Federal, State, and local laws and regulations, including HIPAA and the integrity of Protected Health Information (PHI).
• Maintains SoNE HEALTH Standards of Conduct, as well as other policies and procedures. 
• Educates patients, family and other health care members on the role and purpose of Care Coordination, its processes, disease/case management programs and outcomes and follows Population Health Management.
• Maintains positive communication and attitude as an effective agent for change with stakeholders and internal team members.
• Attends required meetings, participating in committees and/or in completing special projects as needed.
• Maintains scope of practice and annual competencies for nursing state licensure.
• Performs other duties as assigned.

The duties listed above are intended only as illustrative of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar or a logical assignment to the position.

EDUCATION:

• Graduate from accredited School of Nursing in Bachelor of Science in Nursing (BSN).
• Current RN license with Connecticut and Massachusetts.
• CCM, ACMA, or other case management certification preferred.

EXPERIENCE:

• Three (3) years or more years of RN nursing experience, preferably with a minimum of 2 years in acute care setting and minimum 1-2 years in ambulatory or case management setting including care coordination and telephonic triage.
• Bilingual in Spanish preferred.

SKILLS:

• Knowledge of patient care delivered in the ambulatory setting, valuing the vision, mission, and strategies of Population Health in offering value-based care by improving patient care, enhancing patient experiences, reducing healthcare costs, and improving provider satisfaction for stakeholders.
• Knowledge of evidence-based practice for complex, chronic conditions and diseases, such as, but not limited to, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes (Type I and II), end-stage renal disease (ESRD), and chronic kidney disease (CKD).
• Knowledge of federal and state laws relating to nursing/clinical care, professional ethics related to the delivery of nursing/clinical care.
• Knowledge of chronic illnesses such as cancer, substance misuse, or mental illness.
• Knowledge and application of holistic nursing care, including psychosocial assessment, use of PHQ2/PHQ9 Depression screening tools and workflows.
• Knowledge of case management service delivery, including value-based care.
• Knowledge of Medicare and/or Commercial insurance guidelines and quality measures pertaining to patient care management in the ambulatory/community care setting is preferred.
• Demonstrates ability of working effectively within an interdisciplinary team, displaying safe clinical judgment and autonomous decision-making skills. 
• Demonstrates flexibility in changing healthcare environment.
• Motivated, result-oriented with strong skills in presenting, communicating, organizing, multi-tasking and time management.
• Strong organizational and interpersonal skills.
• Excellent customer service skills demonstrated by positive feedback from patients/team.
• Ability to facilitate and coordinate interdisciplinary meetings.
• Ability to identify problems and recommend solutions.
• Ability to read, write and communicate effectively orally and in writing.
• Ability to shift priorities based on changing needs within healthcare environment.
• Ability to travel to network provider practices, hospitals, skilled nursing facilities, and other sites where patients receive care as needed.
• Ability to perform job with integrity and values consistent with the organization’s Mission, Core Values and Standards.
• Basic computer skills.
• Proficiency in using Microsoft programs such as Excel, Teams, and Outlook.
• Familiarity with Multifactorial Authentication (MFA).
• Proficiency with an electronic medical record (EMR) such as Athena.
• Maintains Protected Health Information (PHI) with strict confidence and in a professional manner. 
• Understanding of nationally recognized standards of care, managed care methodologies, and an awareness of dynamics occurring within the healthcare delivery system.
• Familiarity with Accountable Care and the Patient Centered Medical Home Model a plus.

PHYSICAL AND MENTAL REQUIREMENTS:

The Physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of the job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Ability to work long hours – over eight in a workday, and over 40 in a work week as necessary.
• Regularly required to use hands to finger, handle or feel objects, tools, or controls; reach with hands and arms; and talk or hear. 
• Frequently is required to walk and sit. 
• Occasionally required to stand; climb or balance; and stoop, kneel, crouch or crawl. 
• Ability to lift and/or move up to 20 pounds. 
• Vision abilities required by this job include close vision, color vision, peripheral vision, depth perception and ability to adjust focus. 
• The dexterity necessary to utilize a computer keyboard on a regular basis is essential.

ADDITIONAL REQUIREMENTS:

• Conditional to SoNE HEALTH employment, employees must reside in Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, or Vermont.
• Proof of Influenza vaccination.
• Smartphone required.
• Remote or hybrid work capacity with stable internet connection that has an internet service provider with speeds of at least 30Mbps download/5Mbps upload. 
• Ability to work from office-setting as needed.

Adherence to SoNE Code of Conduct:

Code of Conduct: Employee will understand and follow the guidelines and standards outlined in the SoNE HEALTH Code of Conduct and demonstrate an understanding of the SoNE HEALTH Mission, Vision and Core Values.

Policies and Procedures: Employee will comply with all SoNE HEALTH policies and procedures relevant to their role, including those related to compliance, safety and confidentiality.

Regulatory Requirements: Employee will ensure actions and behaviors are in accordance with applicable laws, regulations, professional standards, policies, procedures and the Code of Conduct.

SoNE HEALTH BENEFITS:

We offer a competitive compensation package, which includes a comprehensive benefits program that begins on the first of the month following date of hire. 

Our benefits include:

• Medical, dental, and vision insurance
• 401(k) retirement plan with employer match
• Short-Term Disability Insurance
• Long-Term Disability Insurance
• Basic Life & Accident Insurance
• Flexible Spending Accounts
• Voluntary Benefits
  1. Homeowners Insurance
  2. Auto Insurance
  3. Critical Illness Insurance
  4. Pet Discount Plans
• Earned time off, sick time, company holidays and one floating holiday
• Paid Volunteer Time
• Employee Assistance Program
• Educational Assistance (Tuition Reimbursement) after one year of employment
• Employee Discount Program for discounts on entertainment, travel, and shopping