The Orthopaedic Institute is seeking a highly motivated case manager to work as part of a multidisciplinary team serving the Medicare population. The case manager will provide telephonic case management/care coordination to Medicare members enrolled in the Bundled Payment for Care Improvement Advanced Initiative. [Medical Group] strives to work collaboratively with our patients, providers and care givers throughout the continuum of care to ensure a quality outcome and patient satisfaction.
Job Role and Responsibilities:
• Responsible for managing a group of Medicare orthopedic patients throughout a ninety day episode of care, as part of the Bundled Payments for Care Improvement Advanced Initiative.
• Gather clinical information from the EMR and telephonic health assessments to determine risk stratification. This includes a comprehensive assessment of physical, emotional, psychosocial, and environmental needs of the patient.
• Document clinical assessments and care plans in designated case management system.
• Educate the patient and caregiver of the process and expectations of the health care delivery system throughout the course of care to include Acute, IRF, SNF, LTAC, Home Care, and outpatient services.
• Establish and implement care plan throughout the transition of care to ensure the patient’s well-being.
• Evaluate plan of care and revise as needed based on patient's health status, and communicate changes to all other disciplines involved in the patient's care.
• Collaborate with multidisciplinary team members in the acute, post-acute and outpatient settings to identify patient needs such as home health care, DME, physical therapy and community services.
• Follow up with patients at pre-determined intervals and as needed based on patient status (in person or by telephone).
• Complete and submit all required documentation within established guidelines.
• Communicate with providers and multi-disciplinary care team members to facilitate transition of services throughout the continuum of care.
• Identify gaps or barriers in treatment plans to ensure that discharged patients receive appropriate resources and services.
• Understand the Bundled Payment program design, implementation, management, monitoring and reporting requirements.
• Remain flexible and responsive when changes occur in patient activity and workload.
• Adhere to the scope of practice for the Registered Professional Nurse per state regulatory guidelines.
• Maintain confidentiality of all patient information per HIPAA and Signature Care Management guidelines.
• Perform other duties as assigned.
• Current unrestricted RN license
• BSN preferred, with 2-3 years of experience in case management, discharge planning or outpatient care coordination
• Medicare or Medicare Advantage experience preferred
• Geriatric experience a plus
• Proficient computer skills
• Excellent interpersonal and customer service skills
• Ability to work independently
The Orthopaedic Institute is a group of fully trained, experienced, specialty physicians providing the complete spectrum of musculoskeletal care from prevention and diagnosis to treatment and rehabilitation.
Role: Nurse Case Manager
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