Nurse Care Manager, Clinical Operations - Bend, Oregon

About Our Company

We’re a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care.

Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians.

When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care.

Please Note: We will only contact candidates regarding your applications from one of the following domains: @summithealth.com, @citymd.net, @villagemd.com, @villagemedical.com, @westmedgroup.com, @starlingphysicians.com, or @bmctotalcare.com.

Job Description

Position Summary:

The RN Care Manager will participate in a dynamic interdisciplinary team to provide case management services to identified complex, high-risk patients across the care continuum. The Care Manager will partner with patients and families by engaging them in the accountability of care in order to improve patient experience. The Care Manager will achieve goals of lowering costs and improving clinical outcomes by serving as an integral primary care team member, managing assigned populations of patients, and coordinating care for patients identified with potential avoidable utilization, gaps in care, and/or at-risk status. Responsibilities may include development of care plans, collaboration with external agencies, case conferences, self-management support and health coaching.

Essential Job functions:

· Works with multidisciplinary transitional care team to facilitate seamless patient transitions across the continuum of care.

· Assesses assigned population of patients. Independently prioritizes care management needs (high need, high-risk and/or high cost).

· Applies case management concepts, principles and strategies to assist the high-risk patient in achievement of prevention and treatment goals.

· Care plan development and monitoring for the highest need/highest cost patients in collaboration with the Primary Care Physician.

· Documents appropriately in the electronic health record, care management registry and any required patient tracking documents. Employs appropriate and timely use of tasking in the EHR. Reviews and updates medication and problem lists.

· Performs all care management activities across the continuum of care while adhering to the core values of patient confidentiality, privacy, safety, advocacy, and adhering to ethical, legal, and accreditation/regulatory standards.

· Delivers care management services within the scope of licensure in accordance with SMG policy.

· Assumes accountability for the quality of care.

· Continually seeks new knowledge and learning regarding comprehensive primary care and chronic disease management.

· Other duties as assigned.

General Job functions:

1. Transitional Care Management:

• Ensures that all assigned “Hospital Discharge” and “Rehab Discharge” tasks in the EHR are addressed in a timely manner, identifying whether the patient requires follow up with primary care or a specialty department at SMG.

• Performs telephonic outreach to patients within 2 business days of discharge.

• Documents all the elements for transitional care management in an Encounter in the EHR.

• Ensures that the Transitions of Care note is sent to the appropriate PCP for review and signature in the EHR.

• Schedules follow-up appointment(s) for patients in EMR. High complexity patients are scheduled within 7 calendar days post discharge. Moderate complexity patients are scheduled within 14 calendar days post discharge.

• Follows the patients’ status for 30 days, updating the Primary Care Physician and communicating with family members as needed. Ensures outreach to patient post discharge day #30 to confirm that patient has not been readmitted.

• Provides continued intense care management to the highest risk patients beyond the 30-day period as clinically warranted.

2. High-Risk Patient Identification and Management:

• Identifies high need, high-risk and/or high cost patients through Transitions of Care, payer-provided data, and physician referrals.

• Performs full chart review taking into account chronic disease(s)/disease burden, significant risk factors, polypharmacy/pill burden, functional status, utilization and social issues.

• Risk stratifies patients into 1 of 6 levels of risk utilizing AAFP’s algorithm for risk stratification. Patients in levels 5-6 are placed in high-risk panels for intensive care management.

• Identifies any gaps in care and determines the needs prior to outreach.

• Performs outreach to patients scheduling/facilitating any appointments for needed care with Primary Care Physician or specialist, addressing any gaps in care, providing education regarding disease/illness, medication and self-management.

• Initiates collaborative Care Plan with patients in close collaboration with the Primary Care Physician.

3. Care Plan Development:

• Initiates Care Plans for the highest need/highest cost patients in close collaboration with PCP, patient and family; updates Care Plans as needed.

• Incorporates clinical service team and physician feedback into care management planning.

• Collaborates with all members of the health care team to include members of the interdisciplinary care team (e.g., Social Worker, Clinical Pharmacist, Certified Diabetic Educator, etc), the patient and their family members as appropriate.

• Engages high-risk patients (and their caregivers) in understanding and setting self-management plans in a culturally and linguistically appropriate manner.

• Supports high-risk patients in their health behavior change efforts.

• Provides ongoing monitoring of patient involvement, participation and compliance with treatment plan, updating Care Plan as needed.

4. IS/Care Management Registry:

• Demonstrates ability to use the EHR, care management registry, and all ancillary clinical systems efficiently and effectively for communication and documentation purposes.

• Develops super-user knowledge of the Care Management Registry.

• Utilizes the Care Management Registry to identify and track the top 3-5% highest risk patients.

5. Payer Contracts:

• Demonstrates a broad understanding of payer contracts (e.g., understanding patient attribution, care management requirements, clinical quality metrics, and utilization and cost outcomes).

• Ability to work with payer provided reports.

6. PCMH:

• Demonstrates knowledge of PCMH requirements and standards.

• Ability to implement the workflows that are specific to Care Management.

• Demonstrates the ability to effectively communicate and collaborate with care team members.

7. Competency, Training and Education:

• Maintains core proficiencies /competencies as defined by the Care Management Program.

• Continually seeks new knowledge and learning regarding comprehensive primary care and chronic disease management.

8. Quality Improvement Initiatives:

• Serves as a resource for all current and future quality improvement initiatives within SHM/SMGO.

• Demonstrates ability to appropriately document data discretely in the EMR and serves as a resource for clinical office staff.

Environmental Risks:

· Extreme temperature

Education, Certification, Computer and Training Requirements:

• Bachelor’s Degree required, BSN preferred

• 2 years’ experience in a related Care Manager role or 5 years nursing experience with varied medical exposure

• Valid OR RN License Required

• Valid Driver’s License required

• Certified Case Manager (CCM) preferred

• Certified Diabetes Educator Preferred and/or experience with Diabetes Education and Management

• Demonstrated ability to work in a collaborative team oriented environment

• Ability to communicate in English, both orally and in writing required.

• Proficient Microsoft Office skills preferred

• Experience with standard office equipment (phone, fax, copy machine, scanner, email/voice mail) required.

About Our Commitment

Total Rewards at VillageMD

Our team members are essential to our mission to reshape healthcare through the power of connection. VillageMD highly values the critical role that health and wellness play in the lives of our team members and their families. Participation in VillageMD’s benefit platform includes Medical, Dental, Life, Disability, Vision, FSA coverages and a 401k savings plan.

Equal Opportunity Employer

Our Company provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to, and does not discriminate on the basis of, race, color, religion, creed, gender/sex, sexual orientation, gender identity and expression (including transgender status), national origin, ancestry, citizenship status, age, disability, genetic information, marital status, pregnancy, military status, veteran status, or any other characteristic protected by applicable federal, state, and local laws.

Safety Disclaimer

Our Company cares about the safety of our employees and applicants. Our Company does not use chat rooms for job searches or communications. Our Company will never request personal information via informal chat platforms or unsecure email. Our Company will never ask for money or an exchange of money, banking or other personal information prior to the in-person interview. Be aware of potential scams while job seeking. Interviews are conducted at select Our Company locations during regular business hours only. For information on job scams, visit, https://www.consumer.ftc.gov/JobScams or file a complaint at https://www.ftccomplaintassistant.gov/.

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Acts as a patient advocate and uphold patient rights. Assesses and responds to individual, psychosocial, and spiritual needs of the patient. Administers medications correctly within the restrictions and limitations defined by the New Jersey State Practice Act and the Center’s policies and procedures. Prioritizes and organizes work assignment and adjusts priorities based on changing situations. Promotes and maintains a safe clean and orderly environment. Anticipates potential length of stay or discharge problems. Communicates proactively to the health care team plan of care changes in patient condition, the patient progress, the discharge plan and other relevant information. Participates in discharge planning. Initiates appropriate nursing measures. Communicates and documents change in patients condition to all appropriate individuals. Documents medication use and controlled substance. Appropriately secures patient belongings on admission and throughout discharge. Maintains open collaborative dialogue with the management team. Effectively communicates and interacts with physicians, patients, families and the public. Regularly attends staff meeting, orientations, and in-services. Services on assigned committees. Able to assist with teaching aseptic technique, safety program, infection prevention and control, and relevant nursing topics. Reports promptly and accurately all significant event and problems to the manager. Computer Systems Demonstrates knowledge and the skill understanding and using the Center’s computer system for documentation, charging list reports and inventory. Participates in training classes as needed. Maintains confidentiality of all information in the medical record and assigned computer codes. Professionalism Maintains current knowledge of outpatient post anesthesia / peri-operative nursing practice. Utilizes opportunities for professional growth by attending continuing education programs. Attends seminars and meetings relevant to PACU as requested by the Center. Becomes involved with research, new equipment, procedures for the Center. Maintains and ensures dress code and decorum. Prominently wears name identification badge at all times. Introduces self to patients and patient family members. Promotes good image of Center to patients, physicians, vendors and community. Demonstrates professional behavior by being technically competent, skilled and responsive to the Center's customers in a compassionate, efficient and effective manner. Maintains competencies identified by the Center including but not limited to mandatory education, equipment and skill competency review lists, BLS, ACLS, and PALS as required by patient population. Makes self-knowledgeable as to the contents of the Center's Policy and Procedure Manual. Competently Manages Care of the Post Anesthesia Patient Recovers patients per Recovery Phase I and II policy. Demonstrates knowledge of anesthesia agents. Interprets dysrhythmias, documents, and intervenes appropriately. Keeps family/significant others informed of patient progress. Demonstrates the ability and competency to respond quickly and efficiently in emergency situations. Demonstrates knowledge of surgical emergency preparedness, Malignant hypothermia. Cardiac Arrest, Latex Allergy. Maintains BCLS and code blue competency per policy. Recognizes changes in patient condition and responds appropriately. Reprioritizes and delegates other responsibilities during emergency situations. Functions calmly and efficiently. Proficient in the use of emergency equipment. Checks code cart and emergency equipment according to policy. Documents emergency intervention according to policy. Demonstrates the knowledge of nursing responsibilities regarding anesthesia administration: Able to describe AGA classification code for the surgical patient. Identifies agents and routes used in administration of anesthesia. Identifies risks of all phases of anesthesia and verbalizes nursing actions. General Job functions: Participates in the preparation of the patient for surgery Include as a bullet and other job duties as required. Conducts patient pre-operative phone calls for complete review of medical and surgical history and provides preoperative instructions. Assists in obtaining pre-admission testings (PATs) and medical clearances as needed. Facilitates anesthesiologist's review of PATs and medical clearances. IV placement skills Follows physician orders for administration of pre-operative medications etc. Maintains communication with reception area and O.R.’s to assure efficient movement of patients Implements and insures that physician orders are performed including orders delegated to other health care professionals. Demonstrates understanding and interpretation of diagnostic measures such as lab tests, radiology exams and EKG. Ensures that the Code carts are fully equipped, defibrillators are in operational readiness and that daily checks are completed. Works flexible hours assuming responsibility and accountability for providing patient care. Maintains knowledge of asepsis, infection control and standard/universal precautions. Reduces chances of nosocomial infection by directing attention to infection preventing and control and environmental safety practices. Conducts patient postoperative follow up calls and completes all documentations within the defined timeframe. Performs preoperative assessments and reviews in a timely manner Demonstrates the skill to assume charge nurse responsibilities in the absence of the nurse manager as assigned. Maintains confidentiality of all information and the medical record and assigned computer codes. Actively communicates and supports the Organization's Mission, Values, Ethics, Philosophy, Objectives, and Policies and Procedures. Demonstrates an understanding of how the success of the surgery center is linked to the success or failure of the customer process. Demonstrates safe habits in the work place with a concern for the safety of patients, families, and staff. Maintains current knowledge of the Center's Emergency Preparedness protocols and procedures. Applies OSHA standards. Provides a summary of post-op instructions to patients prior to discharge from the center. Identifies strategies to increase competency of team members Education, Certification, Computer and Training Requirements: Associates degree required. Bachelor’s degree preferred. New Jersey State Nursing License required. BLS and ACLS required. PALS preferred. 2-4 years experience required. 5+ years preferred. Ability to communicate in English, both orally and in writing required. Strong interpersonal and organizational skills required. Ability to perform diverse work assignments with time limitations with a high degree of accuracy required. Ability to use problem solving, critical thinking and priority setting skills required. Must be able maintain annual competencies. Experience with Standard Office Equipment (Phone, Fax, Copy Machine, Scanner, Email/Voice Mail) preferred. Experience with Standard Office Technology in a Window based environment preferred. Pay Range: $40.38 - $50.48 Hourly The provided compensation range is based on industry standards and salary determinations will be made based on numerous factors including but not limited to years of experience and location of position. About Our Commitment Total Rewards at VillageMD Our team members are essential to our mission to reshape healthcare through the power of connection. VillageMD highly values the critical role that health and wellness play in the lives of our team members and their families. Participation in VillageMD’s benefit platform includes Medical, Dental, Life, Disability, Vision, FSA coverages and a 401k savings plan. Equal Opportunity Employer Our Company provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to, and does not discriminate on the basis of, race, color, religion, creed, gender/sex, sexual orientation, gender identity and expression (including transgender status), national origin, ancestry, citizenship status, age, disability, genetic information, marital status, pregnancy, military status, veteran status, or any other characteristic protected by applicable federal, state, and local laws. Safety Disclaimer Our Company cares about the safety of our employees and applicants. Our Company does not use chat rooms for job searches or communications. Our Company will never request personal information via informal chat platforms or unsecure email. Our Company will never ask for money or an exchange of money, banking or other personal information prior to the in-person interview. Be aware of potential scams while job seeking. Interviews are conducted at select Our Company locations during regular business hours only. For information on job scams, visit, https://www.consumer.ftc.gov/JobScams or file a complaint at https://www.ftccomplaintassistant.gov/ .