Job Summary:

The Integra Transitions NCM collaborates with the hospitals and skilled nursing facilities to pursue cost-effective, quality focused management interventions by achieving predetermined financial and clinical outcomes. Responsible for collaboration with the Integra Nurse Care Managers/Transition Managers (hospital and skilled nursing facility based) concerning quality initiatives, outcomes, etc. Responsible for providing ongoing communication with patients, continuing care coordinators, social workers, and physicians to ensure patients have appropriate resources/support in the Hospital and SNF setting and upon discharge to the community and intervening when patients are unable to be managed adequately. Tracks patients along with continuum of care, identifying patterns that have a negative cost-quality impact and assists with the development of plans for improving care.

Duties and Responsibilities:

Applies Case Management principles to the Hospital inpatient and Skilled Nursing Facility (SNF)-patient population to ensure appropriate utilization of resources and level of care. This includes assessing, planning, implementing, coordinating, evaluating, and collaborating with the Hospital/SNF interdisciplinary team, patients, families and community providers.

Assists in the facilitation of discharge planning for Integra ACO patients within the Hospital/SNF setting. This may include but is not limited to, acute rehabilitation admission, initiation or resumption of visiting nurse services, referral to other outpatient providers, transportation, and initiation of outpatient Infusion therapy.

Assists in the identification of patients for Case Management and Social Service referrals during the review process.

Completes all documentation in a timely manner in Epic.

Acts as a resource to the Integra SNF NCM, Integra Transition Managers, ED Hospital Liaison and Community Care Managers.

Engage in process improvement activities that are focused on efficient care delivery and promotes positive clinical and quality outcomes including reducing unnecessary admissions, readmission rates and flow metrics.

Performs related duties as required.

Requirements:

Registered Nurse with bachelor’s degree in nursing or equivalent, Master’s Degree preferred.

Certification in Case Management with current RN Rhode Island license.

Minimum of 5 years related clinical Acute Care or Case Management experience required.

Knowledge of utilization review, quality assurance, discharge planning, third party payer regulations and community health.

Experience demonstrating high level of interpersonal skills, both oral and written, analytical skills, leadership abilities and effectiveness within a team environment.

Care New England Health System (CNE) and its member institutions, Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group, and our Wellness Center, are trusted organizations fueling the latest advances in medical research, attracting the nation’s top specialty-trained doctors, and honing renowned services and innovative programs to engage in the important discussions people need to have about their health.

Americans with Disability Act Statement: External and internal applicants, as well as position incumbents who become disabled must be able to perform the essential job-specific functions either unaided or with the assistance of a reasonable accommodation, to be determined by the organization on a case-by-case basis.

EEOC Statement: Care New England is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status

Ethics Statement: Employee conducts himself/herself consistent with the ethical standards of the organization including, but not limited to hospital policy, mission, vision, and values.