Care Manager - Care Transformation - FT - Day

Skills and Abilities: Demonstrates prudent professional and clinical judgement, effective problem solving skills, critical thinking, excellent organizational and interpersonal skills, creativity, flexibility, and the ability to multi-task. Demonstrates ability to be self-directed and purposeful in seeking the necessary knowledge and skills to enhance professionalism in order to provide high-quality care. Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment. Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals. Demonstrates ability to work autonomously and be directly accountable for practice. Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, priority setting, and work organization. Licenses and CertificationsRegistered Nurse - KSBN Required Basic Life Support - BLS Required within 90 days of hire.

What You Will Do: Actively participates with clinic redesign and Patient Centered Medical Home (PCMH) expansion. Collaborates with primary care staff, social work staff, and other care team members to ensure optimal care coordination for the patient. Establish and maintain a supportive, collegial role with primary care practices engaged in improvement activity, particularly including assigned practices and their individual improvement team members. Initiates communication with patients upon learning they have been identified as high risk / targeted population. Pulls data from multiple systems and merge together to create a complete performance picture related to targeted populations. Implements interventions based on data and established guidelines. Monitors data for trends and individual outliers. Analyzes data for process improvement opportunities to impact patient outcomes. Optimizes patient care transitions by: Assuring an appropriate post-acute plan and utilization of services Assisting the post-acute team in development of an appropriate discharge plan for post-acute discharge. Assures collaboration with primary care, social work & PCP care manager, other care team members, and community supports to ensure optimal care coordination for the patient. Guides patients through the health care system Facilitates interaction and communication with health care staff providers. Provides disease/treatment specific education to both patients and families Oversees scheduled appointment(s) Oversees patient testing and admissions Reviews patient records Efficiently documents medical information using the appropriate forms and/or electronic applications Collects and tracks data related to targeted populations -Implements interventions based on data and established guidelines -Monitors data for trends and individual outliers - Analyzes data for process improvement opportunities to impact patient outcomes Participates in system wide/department patient care quality improvement activities as well as standards developments. Works closely with the cross-functional teams to define analysis needs, identify trends and propose solutions. Appropriately delegates tasks and duties in the direction and coordination of health care team members, patient care, and department activities in accordance with the Kansas State Nurse Practice Act; demonstrates knowledge of KSNPA statutes and regulations.

Travel Requirements: 20% Driving between facilities. Required for All JobsComplies with all policies, standards, mandatory training and requirements of Stormont Vail Health Performs other duties as assigned Patient Facing OptionsPosition is Patient Facing Remote Work GuidelinesWorkspace is a quiet and distraction-free allowing the ability to comply with all security and privacy standards. Stable access to electricity and a minimum of 25mb upload and internet speed. Dedicate full attention to the job duties and communication with others during working hours. Adhere to break and attendance schedules agreed upon with supervisor. Abide by Stormont Vail's Remote Worker Policy and will review and acknowledge the Remote Work Agreement annually. Remote Work CapabilityHybrid ScopeNo Supervisory Responsibility No Budget Responsibility Physical DemandsBalancing: Occasionally 1-3 Hours Carrying: Occasionally 1-3 Hours Climbing (Ladders): Rarely less than 1 hour Climbing (Stairs): Rarely less than 1 hour Crawling: Rarely less than 1 hour Crouching: Rarely less than 1 hour Driving (Automatic): Occasionally 1-3 Hours Driving (Standard): Occasionally 1-3 Hours Eye/Hand/Foot Coordination: Occasionally 1-3 Hours Feeling: Occasionally 1-3 Hours Grasping (Fine Motor): Occasionally 1-3 Hours Grasping (Gross Hand): Occasionally 1-3 Hours Handling: Occasionally 1-3 Hours Hearing: Occasionally 1-3 Hours Kneeling: Occasionally 1-3 Hours Lifting: Occasionally 1-3 Hours up to 25 lbs Operate Foot Controls: Occasionally 1-3 Hours Pulling: Occasionally 1-3 Hours up to 25 lbs Pushing: Occasionally 1-3 Hours up to 25 lbs Reaching (Forward): Occasionally 1-3 Hours up to 25 lbs Reaching (Overhead): Occasionally 1-3 Hours up to 25 lbs Repetitive Motions: Occasionally 1-3 Hours Sitting: Occasionally 1-3 Hours Standing: Occasionally 1-3 Hours Stooping: Occasionally 1-3 Hours Talking: Occasionally 1-3 Hours Walking: Occasionally 1-3 Hours Working ConditionsBurn: Rarely less than 1 hour Chemical: Rarely less than 1 hour Combative Patients: Rarely less than 1 hour Dusts: Rarely less than 1 hour Electrical: Rarely less than 1 hour Explosive: Rarely less than 1 hour Extreme Temperatures: Rarely less than 1 hour Infectious Diseases: Occasionally 1-3 Hours Mechanical: Rarely less than 1 hour