Rochester Regional Health High Risk Care Manager (RN) - GRIPA in Rochester, New York

High Risk Care Manager (RN) - GRIPA

Rochester, New York

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Through the pursuit of advanced degrees, development through our clinical ladder, or exploring roles within our career pathways, we’ve made it our mission to help nurses learn and grow in their careers. Experience an opportunity that comes with a large health system with a family feel.

  • Schedule: Various Shifts

  • Level: Mid

  • Salary: Offers competitive compensation

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Job IDREQ_95346FACILITYVarious LocationsLOCATIONRochester, New York

Job Objectives

High Risk Care Managers are responsible for orchestrating care management (CM) across the continuum for high risk persons enrolled in health benefit plans that GRIPA has contracts with and are patients of GRIPA physicians to provide higher quality, lower cost health care. Requires collaboration with the GRIPA Medical Director, physicians, care managers, social workers, other entities (insurance company staff, Rochester Regional Health providers, home health providers), and all other health care professionals at various sites of service.

Job Responsibilities

I. Clinical Practice:

Implements the GRIPA care management process. This process includes:

Identification:reviews data analysis findings in a timely manner to identify patients on the inpatient and outpatient setting meeting predetermined triggers such as high cost/high utilization, high risk and multiple co morbidity or receive direct referrals from physicians.

Assessment:(see CMS 102) : review all patient health information/documentation available to care managers including physician’s electronic medical records, Care Connect electronic medical record, the GRIPA Connect portal and chart reviews. Assess psycho-social functioning, barriers to care i.e. strengths and weaknesses.

Implementation:Care plan development & Implementation of interventions: Provides patient directed (1:1 or group visits) general & disease specific education, psychosocial support, community resource links based on identified needs via referral and data analysis. Goal of Care Manager interventions are for patient to achieve self-management of health and disease and decrease preventative hospitalizations and emergency room visits.

Coordination of patient care:Facilitates a team approach and fosters a positive working relationship with members of the health care team. Works in collaboration with patient/caregiver/family, primary care physician, and all pertinent members of the health care team to assess, facilitate, plan, and advocate for quality, cost-effective, and appropriate services to meet the patient’s health needs on an individual basis. Provides notification of care management activities to patient’s PCP and other ancillary providers. Actively participate in rounds on complex patients with a multi-disciplinary team.

Monitoring/measuringof patient progress through direct communication with patient and health care providers as well as data analysis.Documentation:Ensures timely and complete documentation following any patient related contact per department documentation policy/procedure. Facilitates quality, cost-effective medical and benefits management.

Monitors their effectiveness in decreasing preventative hospitalizations and ER visits and other unnecessary use of health care resources.

Reports on successes as well as areas where there are opportunities for improvement.

II.Clinical Integration/ACO Efforts

a) Provides physician/office staff directed education, support, and linkage to community and health plan resources based on customized requests, data analysis, feedback and/or individual performance against standards of care.

b) Supports of adoption of electronic health information systems (e-prescribing, EHR, portal) for improving the efficiency, accuracy and integrity of our healthcare system.

c) Participates in performance monitoring activities as needed.

d) Ensures consistency and collaboration of patient care through the use of clinical integration

e) Attends health fairs or other health related events for contracted companies

f) Participates in the health coach program, by teaching and/or working directly with students who serve as health coaches

g) Incorporates “student shadowing” into work activities including patient face to face visits.

III. Company Centered Activities

a) Accurately tracks and reports time usage related to Care Management.

b) Participates in department quality monitoring and quality improvement initiatives.

c) Contributes to GRIPA communications (newsletters and other publications) as necessary

d) Participates in the orientation of new staff, acts as preceptor to all new employees on the team.

e) Provide in-service education or training material to GRIPA staff, and other healthcare professionals as deemed necessary, or as requested.

IV. Professional Development/Education

Maintain professional licensing as required by New York State, and show evidence of satisfying licensing requirements at time of renewal. Demonstrates ability to perform critical analysis, plan, and organize effectively, promoting member/family autonomy. Maintain current knowledge base relative to clinical practice, care management, disease management, and literature for the development of pathways and assessment tools to identify high risk care needs related to nursing, social needs, and/or mental health. Maintain a current knowledge base in community resources, funding, clinical standards, and outcomes. Adheres to all departmental policies, procedures, and established standards Maintains professional competence as evidenced through attendance in continuing education programs. Consistently present a professional image through personal interactions, phone manners, and appearance.

V. Other duties as assigned

VI. Other Requirements

New York State Driver’s License Independent means of transportation Physical Ability to Travel Passing of Pre-employment and annual physical screenings.

Rochester Regional Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran

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