JOB TITLE: Continuing Care Manager (RN CCM)

JOB CODE:001173 TBD

PAY GRADE:TBD

OSHA LEVEL:I

DEPARTMENT: Primary Care

REPORTS TO: Nursing Leader

SUMMARY:

Under direction of the Nursing and Physician Leader and in collaboration with the patient care team, identify patients to provide care coordination services for. Function as a resource to patients and families and actively role model patient and family centered care.

RESPONSIBILITIES:

Care for patients with high complexity utilizing holistic approach.
Use the nursing process to assess and develop a patient/family centered plan of care.

Perform a comprehensive nursing assessment to include health and disease management, functional status, cognitive capability, and available support systems for patient families. Also perform assessment of psychosocial functioning, environment and financial resources.
Develop a comprehensive patient/family centered interdisciplinary plan of care, incorporating biological, psychosocial, social, and health system domains.
Implement and monitor plan of care. Ensure regular updates and revisions to care plan. Assist patient with development of long and short term goals. Assess unmet needs, strengths and assets of patients and their families.
Facilitate referrals to various programs, agencies, physicians, etc. to assist the patient in overcoming the barriers to managing their health/wellness.
Manage benefits and negotiate continuing care services for enrollees in various health insurance plans.

Coordinate patient care.

Facilitate communication between the patient, family, provider, other practice team members, specialists, other providers, social work, therapists, and community resources.
Ensure completeness of, and access to, patient’s health information and care plan by all appropriate parties.
Manage and coordinate clinical care of defined populations across the continuum of care.
Identify and refer to a health coach, if provided by health plan or employer.
Identify needs of the patients/family and refer to community resources.
Identify needs for a home environment and safety evaluation and take steps to procure same.
Develop strategies with healthcare team to advocate for patient needs.
Utilize innovative strategies to advocate for patient needs and negotiates complex systems to remove barriers and limitations in accessing health care.

Act as a liaison by consulting and collaborating with other care managers and care coordinators and providers to share assessment and plan of care as the patient moves through difference care settings.
Identify gaps in the care continuum and work with the community and provider networks to expand access to needed services.
Promote optimal health/wellness and development of self-care skills.

Perform pre-provider visit planning to ensure productive, effective patient-provider interactions. Perform post-provider visit wrap-up and between visit contact to ensure patient understanding of the treatment plan, develop patient driven goals and strategies to maximize patient ability to meet health specific goals.

Provide individual patient/family education and self-management support that is appropriate based on language, cognitive abilities, literacy level, learning style, cultural norms, patient preference, readiness for change and resources available
Participate, as appropriate, in provider visits.
Lead shared medical appointments, group visits, and/or support groups.
Identify gaps in the care continuum and work with the community and provider networks to expand access to needed services.

Engage in quality improvement projects

Lead and participate in quality improvement projects for team and/or the practice and/or system, especially related to the management of patients.
Counsel and guide a caller through their healthcare choices by accessing the patient education knowledge bases, library resources, Shared Decision-Making videotapes and the Internet for research.
Lead patient care conferences in conjunction with peers and the clinical team.
Participate in continuous learning through self-study, case review, case conferences, grand rounds, and continuing education.
Identify and facilitate opportunities for system-wide improvements in care processes (disease management coordination, workflows, multi disciplining team).
Identify opportunities for enhancing learning opportunities and provide to colleagues.

Participate in continuous learning through self-study, case review, case conferences, grand rounds, and continuing education. Pursue scholarly research and publications.
Protect patient’s rights and confidentiality by following department/organizational policies.
Perform other duties as required or assigned.

MINIMUM EDUCATION & EXPERIENCE: Registered Nurse with bachelor’s degree and master’s degree (or matriculated into a master’s program) with current NH and VT licensure. A minimum of five years of clinical experience required. Desired skills include: critical thinking, strong leadership abilities, autonomy, communication, negotiation, conflict resolution, and computer use. Desired qualities and behaviors include: collaborative team player, use of systems approach in planning, problem solving, and decision making, creativity, innovation, risk taking, autonomy, flexibility, receptiveness to change, and a commitment to professional growth.

PSYCHOLOGICAL CONSIDERATIONS:
Flexibility, tolerance, and demonstrated ability to take initiative and to prioritize multiple tasks with attention to details. Function at a fast pace and continually interact with a wide variety people and situations while maintaining a customer focus. Able to remain focused and function effectively in a crisis situation. Aware of scope of practice boundaries, comfortable seeking direction and assistance from appropriate resources.

SUMMARY OF PHYSICAL DEMANDS:

Daily demands may vary dependent on specific duties performed. Up to 80%-100% of day may be spent seated while talking on the phone, attending meetings, completing or reviewing paperwork or working on the computer. Up to 75% of day may be spent working in a repetitive motion activity including use of computer and keyboard to access and input information. Must be able to effectively communicate in person and over the telephone. Visual and auditory skills essential to perform patient assessment duties. Fine motor control may be important to perform injections or other procedures. May bend, stoop, or reach to retrieve materials or supplies, push or pull up to 60 pounds, and assist in lifting patients. Must be able to respond to emergency situations. Some travel may be necessary to meet with patients and families in facilities and to attend meetings and/or training.

APPROVED BY:

Department DirectorDate

Job AnalystDate

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