Registered Nurse - Care Manager
Company: The University of Vermont Health Network
Posted on: March 20, 2023
OverviewThe Care Manger position is an integral part of the
healthcare team working closely coordinating inpatient and
outpatient care and services across the continuum of care assuring
and including Primary care and Specialty providers. The Care
Manager utilizes his/her skills to coordinate internal and external
resources to facilitate appropriate resource management of an age
specific patient population which spans from newborns to
geriatrics, identifying opportunities for process improvement, high
risk cases and sentinel events, to the achievement of an acceptable
outcome.-- The Care Manager's role in data collection, analysis and
summarization supports performance improvement/quality programs,
risk management, clinical pathway development and outcome
measurement using guidelines.-- They possess the ability to work
independently as well as collaborate and communicate effectively
with colleagues, supervisors, service delivery partners, other
health care professionals and co-workers to build and maintain
effective, dynamic professional team relationships.---- This
position is an integral part of the Patient Centered Care team. The
Care manager works under the supervision of the Regional Director-
Patent Centered Care Management to support the objectives of UVM
Health Network - CVPH and the Medical Home. Responsible to identify
at-risk patients and develop plan of care based on risk and patient
goals to meet individual health needs through communication and
assisting with access to resources to promote quality,
cost-effective outcomes across the continuum of care.Position
- This is a regular part-time, 56-72 hours per pay period
- Salary Range: $32.14/hour-$47.57/hour
- $10,000 Sign-On Bonus for 1 Year Committment (pro-rated for
part-time)ResponsibilitiesRespect for patient values, preferences
and expressed needs:
- Customize care of each patient, ensuring that it's culturally
and literacy level appropriate.
- Understand patient preferences and optimize care as
- Assess, plan, coordinate and evaluate at-risk patients to
promote healthy living with emphasis on prevention, self-
management and behavioral changes to reduce hospital admissions and
utilization of emergency department.Care coordination and
- Utilize a multidisciplinary approach for the patient's care to
promote a heightened focus on the patient needs/preferences.
- Identify and implement a Patient centered multidisciplinary
- Gather information necessary to accurately assess and address
patient needs and work with multidisciplinary team to develop and
monitor individualized patient centered plan of care based on risk
and patient goals.
- Promote dialogue between patients and providers helping to
guide them through the continuum of services and assist with
transition from hospital to home/alternate level of care
- Support patients to better self-manage chronic conditions to
include: interact with pharmacist related to medications when
required; identification of barriers, behaviors, etc. to promote
- Provide education to patients and their families about care
plan, importance of follow-up with providers, risk factors,
monitoring of symptoms, medication management and available
- Coordinate resources and referrals as identified.
- Establish and maintain effective working relationships with
health care providers.Interviewing, information gathering and
- Understanding, educating and communicates to the patient the
importance of Patient Centered care.
- Integral role that patients participate in creation of their
plans of care in their overall health ----------------
------------and wellbeing.-------- - ----------Patients
participation, in easy-to-understand terms creating there to
overall plan of care.
- Tailor communication to reflect patients' needs IE: open ended
questions to gain insight into the patient concerns or preferences
- Provide, during the process, options of care. Shared decision
allows the patient values and preferences first, discussing the
pros and cons of treatment options.
- Offer educational material, so patients can choose appropriate
treatments to facilitate autonomy, self-care and health promotion.
- Ensure that the patient is physically comfortable to promote
and be actively engaged in patient-centered care as it relates to
- Pain management
- Assistance with activities of daily living
- Familiar with hospital surroundings and their
environment.Emotional support and alleviation of fears and anxiety:
- Evaluate anxiety associated with illness which decreases
- Understand how this illness intervenes their overall wellness
- Evaluate anxiety regarding the financial impact of their
illness.Encourage family and friends in the patient experience:
- Provide accommodations for family and friends.
- Involve family and close friends in the decision making
- Support family and friends as the caregivers to this
patient.Continuity and transition of their care when going
home/alternate level of care :
- Evaluate and provide opportunities for patient to express
concerns about their ability to care for themselves after
- Obtain, but not limited to, insurance authorization for
- Provide information regarding medication, physical limitations,
dietary needs, DME, etc.
- Provide a coordinated approach to the continuum of care with
outside services once discharged; IE: Home Care Agency, Rehab
services, Transitions of Care, Specialty/PCP, etc.
- Refers patients appropriately for Adult homes, Sub Acute,
Nursing facilities, Acute Rehab and Hospice as appropriate, etc.
Completing PRI if required for these facilities
- Provide information related to anticipated services and the
associated cost of those services.Access to care when it is needed
once they are home and in the ambulatory setting.
- Provide information related to access to care once they are
- Work with community based organizations, Primary Care
physician's offices, Specialty physician offices, etc., to assure a
seamless continuum of care.
- Assure that appointments at discharge are scheduled for the
patient prior to discharge.
- Coordinate and assist in following through with Primary care
and specialty appointments.
- Work with the patient/family and other agencies to assure
transportation to appointments is available post discharge.
- Promote healthy lifestyles and improved services throughout the
communities served by the Medical Home. Duties include but are not
- Provide education to promote healthy lifestyles across
populations in the community
- Provide care management supports to patients identified as high
risk by the practitioner or meeting criteria for Health Home
eligibility to ensuring patients are connected and utilizing
community resources for self- management of their disease
states.Maintain skill competency.Demonstrate commitment to
continuing education.Comply with HIPAA and UVM Health Network CVPH
confidentiality policies.Other duties as
assigned.QualificationsCurrently licensed as a Registered Nurse in
New York State required.Three years of nursing experience required,
CCM preferred, Discharge Planner preferred.Preferred experience in
ambulatory care and/or case (care) management.Knowedgable in the
Managed care process preffered.Knowlegdable of regulatory
requirements; IE: DOH, CMS,EMTALA, Joint Commission,
etc.Knowedgable in Medicare, Medcaid, Private insurances, etc.,
preferred.Knowledge of electronic medical records systems; IE:
Sorian, Medent, Care Navigator, EPIC, Microsoft applications,
etc.Ability to develop and maintain effective relationships with
staff, providers, patients and external customers. Good
interpersonal and communication skills. Ability to understand and
commit to UVM Health Network CVPH core values of teamwork,
confidentiality and quality care.Working knowledge of medical
terminology and medications required.Knowledge and understanding of
prior authorization for DME/Medications, etc. Must have strong
verbal and written communication skills. Must have excellent
attention to detail.Ability to effectively manage multiple cases
and projects required. Assessment, goal setting skills, project
management skills, and problem solving skills required.Ability to
make appropriate decisions with a minimum amount of supervisory
direction required.Ability to incorporate evidence based practices
required.Ability/experience with data collection, program
management and reporting required.As applicable, the individual has
training/competency in attending to the special needs and/or
behaviors appropriate to the age of the patients for which care is
Keywords: The University of Vermont Health Network, Albany , Registered Nurse - Care Manager, Healthcare , Plattsburgh, New York
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