Compass Care Reg Nurse Care Mgmt Coord ?
Company: Children's Hospital Of Philadelphia
Posted on: October 13, 2019
Req ID:?25993Shift: DaysEmployment Status:?AF - Active - Regular -
Full Time?Job SummaryThe Registered Nurse (RN) Care Management
Coordinator or ?Care Manager? provides care management services to
a panel of medically complex patients or populations of patients
who have risk factors that are amenable to care management
interventions.? The RN Care Manager may be assigned regionally to
support one or more CHOP primary care practices and/or may be
assigned to the care of patients who receive primary care outside
of the CHOP Care Network.? S/he serves an advocate for patients and
their families and assists them to navigate the health care
system.? The RN Care Manager facilitates the continuity of a
patient?s care by functioning as a liaison between primary care
providers (PCPs), outpatient specialty care providers and inpatient
care teams, as well as payers, medical equipment suppliers, home
care providers, subacute and chronic care facilities and community
resources.? S/he collaborates with ambulatory, emergency department
and inpatient care teams with the goals of optimizing communication
among care providers, promoting seamless transitions between care
settings and facilitating the appropriate use of health care
- General care coordination responsibilities:
- Identify patients in need of care management and maintain a
- Provide care management services to an assigned panel or
designated population of patients and their families.
- Develop and maintain patient-centered, intra-disciplinary,
longitudinal plans of care and monitor patients? progress toward
care plan goals.
- Advocate for patients and families and promote communication
and collaboration to keep all care team care members informed of
patients? care needs and to ensure that patients access and benefit
maximally from available health care resources.
- Facilitate transitions across care settings.
- Assist patients and families with access to health care
services as needed, including collaboration with payers.
- Teach, coach and counsel patients and their families to build
independence and skills for self-management.
- Monitor and evaluate patients? outcomes and communicate
outcomes to health care teams.
- Use information systems to document and track care coordination
- Transfer patients to higher or lower levels of care management
support as appropriate.
- Outpatient care coordination responsibilities:
- Communicate regularly with PCPs and relevant specialists
regarding acute and chronic patient care issues and
intra-disciplinary care plans.
- Review medical records prior to encounters and participate in
outpatient visits as necessary to assist in the development and
updating of care plans.
- Participate in care team meetings to discuss active clinical
issues and progress toward goals.
- Establish routine communication plans and communicate regularly
with patients and families to assess ongoing care needs and to
facilitate proactive care planning, including regular telephone
- Serve as a liaison with insurers/payers, review resource
utilization and eligibility and identify the need for and
facilitate obtaining additional health insurance services.
- Complete letters of medical necessity, referrals and prior
authorizations as needed.
- Collaborate with home nursing companies and Durable Medical
Equipment (DME) providers.
- Identify and develop relationships with community resources to
support patient?s needs and makes referrals when appropriate. Job
- Inpatient care coordination responsibilities:
- Respond to referrals from inpatient teams, primary care
providers or referring hospitals/facilities prior to discharge, and
provide consultation on enrollment in longitudinal care management
- Establish relationships with patients who are newly enrolled in
care management services prior to discharge and collaborate with
the inpatient teams regarding discharge plans and anticipated
outpatient care needs.
- Serve as a longitudinal resource for inpatient teams to obtain
relevant information and updates about patients during admissions,
and collaborate with inpatient teams regarding outpatient care
needs and discharge plans.
- Facilitate scheduling post-discharge follow up telephone
encounters and visits with the PCPs and specialists.
- Coordinate plans for follow up visits with care providers and
for laboratory and diagnostic studies after discharge.
- Attend inpatient family meetings and care conferences when
necessary to integrate inpatient care with patients? longitudinal,
intra-disciplinary care plans.
- Emergency Department care coordination responsibilities;
- Serve as a resource to Emergency Department providers for
information about patients that will inform the Emergency
Department plan of care.
- General registered nursing duties (including but not limited
- Obtain and document patients? histories.
- Perform and document physical assessments.
- Conduct telephone triage and refer patients to appropriate
- Perform and/or interpret basic laboratory tests.
? Professionalism and Leadership
- Assist with surveys and other data collection activities to
measure the effectiveness of care management interventions.
- Support strategies and changes as needed to improve the care
- Serve as an institutional expert on care coordination and
?Job Responsibilities (Continued)Research
- Read, analyze and synthesize nursing and other scholarly
articles and research studies; share knowledge with
- With assistance, apply research findings to clinical
- Seek opportunities to participate in research studies.
- Identify learning needs of self and others and assists in the
development of a learning plan.?
- Apply education and training from departmental in-services and
external sources to unit practices to enhance Nursing
- Participate in the development/presentation of education
- Demonstrate health care informatics competency in order to
manage patient care, outcome data and current and emerging health
- Participate in promoting quality, efficient and cost effective
- Monitor own usage of supplies and equipment/identify
opportunities for improvement and makes recommendations.
- Manage own time to accomplish direct/indirect care in a cost
efficient manner.Required Licenses, Certifications,
RegistrationsRegistered Nursing License or active Temporary
Practice Permit in the Commonwealth of Pennsylvania. Can practice
with a temporary practice permit for 6 months.BLS Certification
issued through on organization that requires a hands-on instructor
lead psychomotor skills verification (ex. American Heart
Association or Red Cross).Certification in Care Coordination and
Transition Management (CCTM) by the American Academy Ambulatory
Care Nursing (AAACN) within three (3) years of being placed into
position.Required Education and ExperienceRequired Education:
BSN?Required Experience: At least five (5) years of nursing
experiencePreferred Education, Experience & Cert/LicPreferred
- Pediatric experience.
- Nursing experience with a combination of outpatient and
inpatient experience.Additional Technical RequirementsComputer
- Navigation and basic search functions of the Internet using
- Use of Outlook 2007 email, opening of attachments, attaching
new files to emails and saving attached files to computer
- Basic use? of computers, printers, monitors, patient care
devices,? and Fax machinesInformation Literacy
- Use of Internet and Intranet to look up basic electronic
resources for practice
- Ability to find and print Patient Family Education Documents
Information Management Literacy
- Navigation of electronic health information records and ability
to review specific patient data in a clinical information
- Understanding of policies and procedures around timeliness of
care, use of a clinical information system and support of safe
- Ability to discuss data presented in charts and tables
- Discuss the responsibilities of each user of an electronic
record related to confidentiality and privacy
- Coordination of patient care information in a fragmented
environment where there is partially online and partially paper
referencesAll CHOP employees who work in a patient building or who
provide patient care are required to receive an annual influenza
vaccine unless they are granted a medical or religious
exemption.Children's Hospital of Philadelphia is committed to
providing a safe and healthy environment for its patients, family
members, visitors and employees. In an effort to achieve this goal,
employment at Children's Hospital of Philadelphia, other than for
positions with regularly scheduled hours in New Jersey, is
contingent upon an attestation that the job applicant does not use
tobacco products or nicotine in any form and a negative nicotine
screen (the latter occurs after a job offer).Children's Hospital of
Philadelphia is an equal opportunity employer. We do not
discriminate on the basis of race, color, gender, gender identity,
sexual orientation, age, religion, national or ethnic origin,
disability or protected veteran status.VEVRAA Federal
Contractor/Seeking priority referrals for protected veterans.?
Please contact our hiring official with any referrals or
questions.CHOP Careers Contact?Talent Acquisition2716 South Street,
6th FloorPhiladelphia, PA 19146?Phone:
Keywords: Children's Hospital Of Philadelphia, Philadelphia , Compass Care Reg Nurse Care Mgmt Coord ?, Healthcare , Philadelphia, Pennsylvania
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