RN Care Manager - Hospital Transition of Care Liaison

People. Passion. Purpose.

P3 Health Partners is a population health management group founded and led by fellow physicians who want to shift the industry’s focus from managing illness to cultivating wellness. We are health plan agnostic and work with most plans in our markets. As the conduit between you and the health plan, we want to make a difference where it counts - with your patients, their families, and the communities where we live. The mission of P3 is simple. We want to help providers and their patients embrace a new kind of care. A kind of care that gives patients the tools and resources they need to manage their long-term health and wellness.

Overall Purpose

Are you a compassionate mission-driven nurse looking to make a meaningful impact on the lives of complex medical patients? As a nurse care manager at P3 Health Partners, you’ll bring hope and healing to patients with complex medical needs. In this full-time role, you’ll be a vital member of an interdisciplinary team, transforming lives and empowering primary care physicians to deliver exceptional care to those who need it most.

The scope of practice includes, but is not limited to, ensuring assigned hospital patient population(s) receive continuous, comprehensive, and coordinated care throughout the continuum.   Through case finding, data and other tools, patients will be identified and guided to enhance the achievement of the Quadruple Aim: improved outcomes, improved experience of care for patients and providers and lower healthcare costs.  

The Hospital- Based- Transition of Care Liaison- RN Care Manager will utilize the nursing process of assessment, planning, implementation, and evaluation as well as clinical judgment.  Interventions with patients and / or stakeholders may be face to face or telephonic.  The RN Hospital-Based Care Manager may be responsible for activities overlapping with utilization review and quality management programs.

You will cover the hospital(s) for which you are hired.

Essential Functions

• Responsible for comprehensive patient assessments through medical records, other clinicians, hospital staff directly involved with a patient’s care, caregiver and patient interviews.


• Have close follow-up with all patients amending care plans as necessary with each patient contact


• Educate patients, their families and/or caregivers.


• Assist patients, families or caregivers’ education and support advanced care planning to include palliative care, and/or hospice care as appropriate.


• Communicate with the comprehensive care team, the hospital care team and primary care physician regarding individualized care plans and patient’s progress.


• Identifies patient care needs and barriers to care.


• Strong clinical judgment and problem-solving skills are required.


• Develops and implements plans to mitigate barriers to patient self-management or self-care.


• Prepares documentation according to P3 health partners workflows and policy.


• Works with patients, families and caregivers to promote self- management and meet care plan goals


• Build relationships with PCPs, internal and external customers.


• Communicate opportunities to advance clinical models.


• Confidently use associated technology and computers.


• Ensure patient privacy and adherence to all HIPAA regulations and standards for handling PHI.


• Ability to participate in flexible staffing should capacity dictate.


• Participate in quality improvement initiatives, documentation audits, and other activities that support clinical excellence and operational efficiency.


• Maintain compliance with required training, timely chart closures, meeting attendance and other requirements.


• Serve as a positive and collaborative team member.


• Role model the P3 Health Partners core values.

Knowledge, Skills, and Abilities

• Active and unencumbered nurse in the state you will practice


• Active case management certification


• Minimum 1 year of case management experience, preferably geriatric medicine


• Strong clinical judgment, problem -solving and critical thinking skills required


• Excellent communication skills with patients, providers, internal and external customers required


• Excellent computer skills


• Must have excellent organizational skills and ability to work independently, with minimal supervision


• Flexible, self-driven and innovative personality

Experience

• Minimum two years of clinical nursing experience, care management, and/or experience with a managed care/HMO organization, required.


• Discharge planning experience preferred


• Understanding of utilization management preferred


• Understanding of HEDIS measures preferred

Education

• Graduate from an accredited school of nursing


• Education: Bachelor’s degree in nursing preferred

Licenses

• Ability to obtain and maintain current Registered Nurse licenses in the states where P3 health partners operates


• Certification Case Management (CCM or ACM) or within 1 year of hire

Travel

• Travel between counties where P3 Health Partners is located in the state hired is required

Pay Range:  $85K-95K