RN Care Manager Value Based Care Institute

The Value-Based Care Institute Population Health Hospital Liaison Nurse Care Manager delivers in-patient care management services to high-risk patients within the VBCI. Working under close supervision, this role communicates effectively regarding the clinical and psychosocial patient information with the healthcare team for case management.

The Hospital Liaison will interact with all levels of personnel, medical staff, patients, community resources, providers, and families to perform case assessment and collaboration for Care Management of eligible hospitalized patients.

Act as a liaison between patients, families, ambulatory care management and healthcare teams to ensure patient needs are met and care plans are followed. Collaborates with physicians, specialists, and healthcare providers to coordinate care and ensure continuity between various treatment settings (e.g., hospital, outpatient, rehab).

Collaborates with inpatient care management team to facilitate discharge planning of high-risk Care Management patients that are exiting the facility to ensure a safe and prompt release. Follows-up to ensure discharge arrangements are understood for high-risk Care Management members to ensure quality care transition.

Provides education and explanations to patients and their families about their condition, treatment options, and discharge plans. Educates healthcare providers and patients about the benefits of the VBCI Population Health programming and services to ensure the utilization of its services.

Offer emotional support to patients and their families during hospitalization and treatment. Address concerns, answer questions, and help families navigate the healthcare system. Provides counseling on post-discharge care, recovery plans, and lifestyle modifications.

Maintains open lines of communication with referring physicians, specialists, and healthcare facilities to ensure seamless transitions of care. Develops and maintains relationships with key stakeholders, such as insurance companies, community organizations, and healthcare providers.

Serve as a point of contact for families and ambulatory care management team during a patient's inpatient stay. Serves as a liaison between the VBCI Care Management team, healthcare team, and the patient population to ensure a quality care transition. Relays pertinent clinical and psychosocial patient information on existing patients enrolled in Population Health programs to the healthcare team.

Assesses patients’ clinical needs and works closely with inpatient and ambulatory case managers to determine appropriate discharge plans and coordination of care. Anticipates and ensure that patients’ healthcare needs are met before discharge by coordinating necessary outpatient care or follow-up services, including but not limited to durable medical equipment, follow-up labs, testing and appointments, home health, community resources, etc.

Helps manage complex or high-acuity patients who may require specialized treatments or interventions post-discharge. Develops clinical expertise in specialty areas and/or chronic conditions and is recognized as a care management resource for high-risk patients with chronic conditions.

EDUCATION:
Required: Graduate from Specialty Training Program - Nursing

Preferred: Bachelor's of Science in Nursing (BSN)

EXPERIENCE:
Required: Minimum of two years’ experience as an outpatient RN Care Manager managing adult patients with complex medical needs and multiple chronic conditions -or- a minimum of 5 years’ experience as a Registered Nurse in an acute care and/or home care setting managing adults.

Preferred: Five plus years’ experience in Care Management with a Certification in a specialty area. A demonstrated history of providing care management services to high-risk adult and geriatric populations in an outpatient setting.

LICENSURE/CERTIFICATION/REGISTRY/LISTING:
Required: Registered Nurse (RN) License: Must have an active RN license in the state where you will be practicing.

Preferred: RN licensure & Certified Case Manager (CCM): Offered by the Commission for Case Manager Certification. BLS (CPR)-American Red Cross or AHA Healthcare Provider