Job Description
This position, is within our Comprehensive CARE Center, a transitional clinic that assists with patients that have recently been discharged from the hospital, helping to coordinate care, educate, and reduce readmissions. In collaboration with a multidisciplinary team, the nurse case manager is responsible for patients who are identified as high or potential high utilizers of the system to assess and assist in the coordination of patient's care across the continuum. Position functions as a clinician, case manager, and educator to achieve optimal clinical and quality outcomes by effectively managing care and resources to reduce unnecessary utilization.



Job Tasks



1. Assessment:
• Identify and assess high risk patients with chronic disease, complex medical, and psychosocial needs referred to the CARE Center
• Complete a thorough assessment with patient's history including medical, physical, social, emotional, psychological and financial needs that will assist the care team in developing a care plan
• Identifies barrier to health care, to include Social Determinant of Health (SDoH), and medical that focuses on the prevention of readmissions.
2. Care coordination:
• Provide telephonic guidance, advice and support to patients
• Accepts responsibility for patients Transition of Care to provide post-discharge follow-up to ensure medication reconciliation, follow-up appointments with PCP or specialist, and other special assistance as needed
• Communicate with multi-disciplinary team any pertinent findings causing a delay in care coordination to ensure safe and efficient services
3. Medication Reconciliation:
• Interview patient/family to identify home medications
• Assess patient/family knowledge of their medications
• Assess patient/family's ability to afford medications
• Review discharge medications
4. Implement plan of care for the patient by performing evidence-based interventions and treatments specific to the diagnosis or problem of the patient: administers treatment such as, lab draws, start IVs, injections, nebulizer treatments, wound care as directed by provider, and monitors patients according to their needs and acuity level. Performs symptom-based standing orders and plan of care.
5. Accurately create a care plan based patients assessed chronic diseases, complex medical, and psychosocial needs.
6. Educate patient on complex medical needs in multiple learning environments, including, but not limited to, (telephonic phone calls, virtual support group, CARE Center visits, remote patient monitoring, home visits).
7. Promote and provide patient self-management, educating patients on disease, medication, access to care, and community resources/referrals to improve clinical outcomes and increase self-efficiency.
8. Conduct individual and group education sessions to assist patient/family in social-emotional needs that are impacted by living with a chronic diagnosis.
9. Maintain accurate timely documentation of actions/services in the appropriate EMR and data collection.
10. Communicate with patients' primary care team (physician, nurse practitioner, social worker, case manager, etc.) regarding changes in patient status and/or care plan.
11. Participate in team-based care. Willingly accept direction from providers and serve as a clinical resource to medical assistants and other practice team members. Communicate proactively.
12. Establish an effective and appropriate means of communicating and collaborating with providers, team members, payers and ancillary services to ensure safe and efficient services.
13. Participate in educational programs and in-services supporting quality improvement and clinical efficiency initiatives.
14. Assist with special projects and other duties as assigned.


Company Description
University of Maryland Upper Chesapeake Health (UM UCH) offers the residents of northeastern Maryland an unparalleled combination of clinical expertise, leading-edge technology, and an exceptional patient experience.
A community-based, integrated, non-profit health system, our vision is to become the preferred, integrated health system creating the healthiest community in Maryland. We are dedicated to maintaining and improving the health of the people in our community through an integrated health delivery system that provides high quality care to all. Our commitment to service excellence is evident through a broad range of health care services, technologies and facilities. We work collaboratively with our community and other health organizations to serve as a resource for health promotion and education.
Today, UM UCH is the leading health care system and second largest private employer in Harford County. Our 3,500 team members and over 650 medical staff physicians serve residents of Harford County, eastern Baltimore County, and western Cecil County.

University of Maryland Upper Chesapeake Health owns and operates:
University of Maryland Harford Memorial Hospital (UM HMH), Havre de Grace, MD
University of Maryland Upper Chesapeake Medical Center (UM UCMC), Bel Air, MD
The Upper Chesapeake Health Foundation, Bel Air, MD
The Patricia D. and M. Scot Kaufman Cancer Center, Bel Air, MD
The Senator Bob Hooper House, Forest Hill, MD


Qualifications

Education & Training: Current Maryland RN license required. Completion of a Bachelor's of Science degree in Nursing preferred.



Work Orientation & Experience: Three (3) years nursing care experience required. Case Management experience preferred.



Skills & Abilities:

Demonstrate skill in a) clinical case management; b) performing complete assessments; c) monitor, assess and record patient progress against a plan of care; d) effective critical thinking skills both written and oral; e) facilitating patient access to community resources; and f) age appropriate interpersonal interactions


Ability to a) communicate and collaborate effectively with both internal and external customers (Medical Staff, multiple-specialty team, management staff, external organizations and general public); b) assess, adapt, and calmly respond to changing and/or crisis environment; c) make independent decisions consistent with current policies, procedures, and ethical standards; d) direct care to include starting lines, performing nebulizer treatments, lab draws; e) prioritize work assignments and manage time effectively to complete duties; and f) assist in data analysis and computer literate in word processing, Excel, and data management skills.


Additional Information
All your information will be kept confidential according to EEO guidelines.