Care Manager – Registered Nurse

COPE Health Solutions is a national tech-enabled services firm powering success for health plans and for providers in risk arrangements. Our comprehensive NCQA certified population health management platform and highly experienced team brings deep expertise, experience, proven tools, and processes to improve financial performance and quality outcomes for all types of payers and providers. CHS de-risks the roadmap to advanced value-based payment and improves quality and financial performance for providers, health plans and self-insured employers. For more information, visit CopeHealthSolutions.com.

The Care Manager (CM) RN will lead a multidisciplinary healthcare team in a primary care / telephonic setting, focusing on coaching and coordination of care for patients needing navigation, addressing nursing care needs and follow up after clinical events. The CM RN will identify the needs of patients at risk and assist the providers to develop processes for managing the patient’s preventative care, transitions of care, and or chronic disease management using defined protocols as well as their own sound clinical judgement. This person will promote patient-centered care, working with primary care providers and medical home team members. The CM RN is a key role in the care coordination of patients attributed to value based contracts. Position Description: The Care Manager (CM) RN will lead a multidisciplinary healthcare team in a primary care / telephonic setting, focusing on coaching and coordination of care for patients needing navigation, addressing nursing care needs and follow up after clinical events. The CM RN will identify the needs of patients at risk and assist the providers to develop processes for managing the patient’s preventative care, transitions of care, and or chronic disease management using defined protocols as well as their own sound clinical judgement. This person will promote patient-centered care, working with primary care providers and medical home team members. The CM RN is a key role in the care coordination of patients attributed to value based contracts.

Evaluates patients for care management services, determines appropriate level of care coordination management for the patient Complete a comprehensive assessment to identify patient risk and develop a care plan utilizing clinical expertise and judgement to evaluate needs for alternative services as needed Work collaboratively with physicians and in-house resources including pharmacists, registered dieticians, social workers and other disciplines to create a person-centered care plan with measurable SMART goals Monitor and update care plan to include progress towards achieving established goals and self-management activities Interact with patient, family and providers and multidisciplinary care team to assess the options of care including use of benefits ad community resources to update care plan. Utilize developed systems, processes, and initiatives to engage patients in relevant case management activities necessary to promote wellness and care at the right place and time. Work collaboratively with physicians and in-house resources including pharmacists, registered dieticians, social workers and other disciplines to support patient adherence to medical plan of care. Supervise and act as a resource for non-clinical staff [i.e. care coordinators, social workers]. Verify that appropriate home care, hospice care, and other ancillary services (DME, infusion services etc.) are in place and are being delivered as directed by the care team Coordinate necessary referrals and authorizations within care management areas Facilitate the information flow between hospital, long-term care, specialists and home health representatives and the care team Use available data and work with physician and office staff to help identify high risk, high need, and potentially high-cost patients Coordinate care and communicate with multiple providers, internal and external to the practice. Identify and utilize cultural and community resources and align with the patient’s cultural preferences as much as possible Verify that members are screened for behavioral health concerns (depression / substance abuse) and are receiving appropriate screening and behavioral health interventions. Facilitate any necessary follow-up behavioral health needs with local behavioral health providers. Attend required training and collaboration sessions [i.e., learning sessions, care management meetings, and practice team meetings] as scheduled. Provide and facilitate open communication, regarding patient status, with physicians and office staff. Obtain records from other physicians/labs/diagnostic centers as requested by the physicians and as needed for care coordination efforts. Develop constructive relationships with internal population health team members, participating providers, and community resources. Other job-related duties as assigned