CMRN-Ambulatory Nurse Case Manager (MNA)

Requirements

• Provides direct referral source servicing at identified facility, building and enriching relationships, identifying needs, problem solving and meeting or exceeding expectations of external customers
• Serves as an extension of the Atrius Health practice site, connecting with Atrius Health patients and/or families to bridge the Atrius Health practice to the patient.
• Conducts review of the medical record for Atrius Health adult medical or surgical hospitalized patients.
• Conducts initial assessment of patient within 24 – 48 hours (business days of admission).
• Subsequent review/progress note at least every 7 days or accompanying a change in condition/plan.
• May provide educational and/or program material to the site facility staff in compliance with Atrius Health clinical initiatives, services and specialty programs.
• Performs needs assessments of patients/families for services including but not limited to primary care, specialty care visits, skilled homecare, palliative care, hospice care (including hospice residence), and/or skilled nursing facility, to ensure appropriateness of services and expedite transitions of care.
• Educates Atrius Health patients/families regarding provider relationships serviced through preferred homecare/SNF organizations.
• Assesses adult medical/surgical Atrius Health patients for risk of readmission, and communicates identified risks with transition of care, outpatient case manager and/or primary care team.
• Facilitates real-time review of contributing factors to readmission of patients and explores opportunities for acute care hospitalization (ACH) reduction.
• Accesses Atrius Health patient’s Epic medical record to determine current program enrollment for continuation of care.
• Assesses patients admitted with Heart Failure (HF) or Chronic Obstructive Pulmonary Disease (COPD) for HTM/RPM and initiates referral to the appropriate program.
• Initiates a referral to the Atrius health heart failure program when appropriate
• Collaborates with hospital-based case manager to facilitate advance care planning documents such as health care proxy or MOLST form.
• Facilitates communication between patient’s hospital-based care team and practice based primary care team when needed or requested.
• Collaborates with transition of care team and hospital-based case manager to ensure post-hospital follow up visit is scheduled.
• Provides supportive patient/family education for targeted diagnoses including heart failure, diabetes, COPD to ensure optimal preparation for home discharge.
• Coordinates with the hospital-based case manager to facilitate regarding Atrius Health preferred provider networks
• Seeks opportunities to improve communication and collaboration amongst all clinical partners in patient care. treating facility and internal/external partners or provider
• Collaborates and communicates with Manager and Atrius Health Case Manager to identify and address any issues or concerns.
• Documentation: Maintains accurate records of the discharge planning process in the patient's medical record for legal, regulatory, and billing purposes.
• Participates in service recovery as needed.
• Promotes problem identification, resolution to barriers in care delivery, efficiency, productivity and customer satisfaction.
• Builds relationships with physicians, referral sources, managed care and assigned facility(ies).
• Provides information, resource materials and education to all providers and case managers and solicits feedback.
• Promotes Atrius Health specialty programs designed to meet the needs of patients, providers, and partners.
• Assists with other referral source account coverage as needed.
• Performs other duties as requested.

Benefits

• Up to 8% company retirement contribution
• Generous Paid Time Off
• 10 paid holidays
• Paid professional development
• Competitive health and welfare benefit package