Job Summary:

Works with appropriate members of the health care team to ensure coordination of patient care along the full care continuum. Through their intervention, they will promote the efficient and appropriate utilization of resources, identify and address care gaps, promote health behavior changes for patients to better manage their illness and recovery (if not chronic), analyze readmissions to the acute setting post hospitalization and facilitate post-acute discharge transition arrangements. As a result of their involvement there will be optimal clinical, financial, functional and health status improvements in the target population.

Essential Functions:

• Collaborates with physician and multidisciplinary team in identifying appropriate patients for care management review, utilizing established care management criteria.
• Assesses, plans and coordinates care on select patient population.
• Seeks and evaluates available options and services to meet an individual’s health needs and care team recommendations.
• Promotes patient self-management and empowers patient/families to achieve optimal levels of wellness and independence.
• Collaborates with the healthcare team members at hospitals, clinics, residential care facilities or other settings, and health insurance payers to facilitate care across the continuum and optimize clinical and financial outcomes.
• Serves as a liaison to providers, patients and families for coordination of services.
• Provides resource information that enhances patient and family competence and capacity to expedite decision making.
• Analyzes data or other materials for identified care management metrics and quality improvement initiatives.
• Effectively applies, interprets and communicates clinical guidelines, policies, procedures, regulations and standards to key stakeholders.
• Advocates on behalf of the patient and the organization to promote safety, quality and appropriate resource utilization.
• Actively engages with providers to promote quality and effective use or resources across the continuum of care.
• Identifies opportunities to achieve clinical process excellence through a thorough analysis of available data and involvement of inter-disciplinary teams.
• Informs and provides required notification to patient and/or personal representative regarding patient status and determination
• Leads readmission reduction efforts including risk satisfaction, pathway assignment, development and education of patients, physicians, and staff.
• Responsible for overall care coordination, efficient resource utilization and discharge coordination of all patients during the hospital stay.
• Uses discretion and independent judgment in recommending appropriate clinical settings and levels of care for individual patients by applying approved utilization management criteria and guidelines.
• Other duties as assigned by management.

Required Education and Experience:

• Minimum Associate’s Degree in accredited nursing program
• Two (2) years of acute or long-term care experience
  • Additional related experience may be considered as a substitution for a portion of the acute care experience

Required Licensure and Certifications:

• Current Oregon State RN license
• Current AHA BLS Certification

Required Minimum Knowledge, Skills and Abilities:

• Must possess analytical and critical thinking skills as well as the ability to prioritize (testing may be required)
• Able to communicate with patients, families, and all levels of healthcare providers
• Able to work independently