Nurse Care Manager

Job Description

JOB SUMMARY

Health Federation of Philadelphia is launching a new care management program aimed at reducing health inequities, addressing social determinants of health, and improving health outcomes for low-income patients struggling with chronic physical and mental health conditions. We are seeking an experienced Nurse Care Manager who is familiar with the pace of, and populations served by, community-based health care providers in Philadelphia.

This position will be part of a team of four, including the Team Manager (a Social Worker) and two Community Health Workers who will work with six community health centers and a Medicaid Managed Care Organization (MCO) to achieve improved outcomes for health center patients enrolled with the MCO and attributed to one of the health centers.  Following the startup phase, the Team will work to assess needs of identified patients at high risk of poor health outcomes, and to engage these individuals in primary care and other services, with the goals of improving health status and reducing hospitalizations, as well as to address quality metrics and “care gaps”.  The Care Management Team will  engage patients who are not receiving regular care at their assigned primary care location and follow-up with individuals with recent hospital contact (inpatient and/or Emergency Department).

As the primary clinical professional on the team, the Nurse Care Manager is responsible for managing vulnerable patients to promote effective education, self-management support and timely healthcare delivery, with the goal of achieving optimal quality and financial outcomes. This position is primarily telephonic with limited face-to-face patient contact.

Qualifications

JOB SPECIFICATIONS

Responsibilities/Duties:

·         Collaborate in the development and implementation of workflow, processes, and ancillary materials for patients attributed to health centers and designated as “high risk” or who have experienced care transitions.

-          Work with the Manager to develop priorities across the patient panel, plan strategies for outreach and engagement, and deploy community health workers in support of priorities.

-          Effectively engage identified individuals in Care Management services, using telephonic and in-person outreach.

-          Perform initial and periodic holistic assessments for care managed population. Prioritize patients according to intensity, need, and required follow up.

-          Formulate and implement a care management plan that is mutually agreed upon by the health care team and the patient/family.

-          Perform medication management, including reconciling discharge medications with ongoing medication regimens and develop a patient-directed self-management strategy for compliance.

-          Perform follow up calls for patients recently discharged from acute hospitalizations and who are considered to be high risk for readmission. As needed, perform hospital visits and/or home visits.

-          Collaborate with health center based providers, inpatient facilities, the Medicaid MCO, and skilled nursing facilties to manage care across the healthcare continuum and optimize clinical and financial outcomes.

-          Determine and complete appropriate referrals. Serves as a liaison to providers, patients and families for coordination of services.

-          Work collaboratively with the Medicaid MCO team for clinical consultation, mobilization of resources, and effective documentation of care for appropriate payment.

-          Maintain accurate and timely documentation.

-          Maintain constant communication with health center care teams to insure that all members of the patients’ healthcare team are informed and duplication of effort is avoided.

Education:

Registered Nurse. Bachelor of Science in Nursing or Masters-level training a plus.

Licensure as a Registered Nurse in Pennsylvania

Required Qualifications/Skills:

-          At least 2 years of experience as a nurse care manager, with a focus on vulnerable individuals struggling with chronic physical and/or mental health conditions.

-          Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.

-          Demonstrates ability to work autonomously and be directly accountable for practice.

-          Demonstrates ability to function effectively in a fluid, dynamic and rapidly changing environment.

-          Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, work delegation, and work organization.

-          Demonstrates ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.

-          Demonstrates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.

-          Adept with technology and data, including electronic health records, payer portals, Microsoft office, and Google apps.

-          Understands the workflows and challenges of busy primary care offices.

Preferred qualifications:

-          Community health center and/or Medicaid program experience a plus.

-          Ability to work with patients in language other than English (especially Spanish).

Position Type and Work Schedule
This is a full-time, exempt position. 

Work Environment
Standard office setting, plus regularly scheduled meetings, trainings, etc. with participating health centers, occasional home or hospital visits.
 

Physical Demands
Able to sit and work at a computer keyboard for extended periods of time.  Able to lift and move up to 15 pounds.
 

Travel
Must be able to get around effectively within Philadelphia and surrounding counties, either on public transportation and/or in own vehicle.  Limited travel beyond surrounding counties will be required, as well.
 

Salary and Benefits
$70-80,000 annually depending on experience and qualifications
 

Our employees are our most valuable resource, so we offer a competitive and comprehensive benefits package, which can include:

·         Medical with vision benefits

·         Dental insurance

·         Flexible spending accounts

·         Life, AD&D and long term care insurance

·         Short- and long-term disability insurance

·         403(b) Retirement plan, with a company contribution

·         Paid time off, including vacation, sick, personal and holiday

·         Employee Assistance Program
 

Eligibility and participation is handled consistent with the plan documents and HFP policy.

DISCLAIMER

The Health Federation reserves the right to modify, interpret, or apply this job description in any way the Company desires. The above statements are intended to describe the general nature and level of work being performed by an employee assigned to this position. This job description in no way implies that these are the only duties, including essential duties, responsibilities and/or skills to be performed by the employee occupying this position. This job description is not an employment contract, implied, or otherwise. The employment relationship remains “at will.” The aforementioned job requirements are subject to change to reasonably accommodate qualified disabled individuals.

The Health Federation of Philadelphia (HFP) is an Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, age, national origin, disability, veteran status, sexual orientation or preference, marital status or any classification protected by federal, state or local law.

Additional Information

All applicants must apply to the position through the following link. Also, please upload a resume and cover letter when applying.

https://www.paycomonline.net/v4/ats/web.php/jobs/ViewJobDetails?job=36479&clientkey=703E6F23E139A9E15CD4746A9D25637D