Job Description

Location: Steward Health Care Network
Posted Date: 7/13/2021

Steward Health Care Network (SHCN) takes pride in its community-based care model, which drives value-added tools and services to our communities, patients, physicians, and hospitals across the continuum of care. In addition, Steward Health Care Network promotes care coordination and collaboration within the network in order to provide high-quality, efficient care to patients. With Steward in the community, all residents can be sure that there is a world-class doctor close to where they live.

The network is also responsible for the implementation and execution of our managed care contracts, medical management services, quality improvement programs, data analysis, and information services.

Position Purpose: Under the direction and supervision of the Regional Executive Director of Clinical Performance, the RN Chronic Care Manager will assist the Primary Care Physician and Chronic Care Management team to coordinate and manage eligible patient’s medical plan in the most efficient, cost- effective manner.

  • Ensures the appropriate delivery of services through Assessment and Case/Problem Identification, Coordination, Planning, Monitoring, and Evaluation.
  • Ensure referrals into Chronic Care Management (CCM) program meet CMS eligibility requirements and patients have properly opted into the program.
  • Facilitate delivery of care plan to patient and providers as appropriate. Update and revise care plans as applicable/required.
  • Coordinate the delivery of services by establishing relationships with all health care providers, health plans, facilities, and community resources, ensuring appropriate utilization across the continuum of care.
  • Has a full understanding of the payer’s benefits, CCM criteria and regulations and works within those reimbursement systems
  • Collaborates with the patient’s care team including but not limited to: hospital team, primary care team, specialists, home care, SHCN clinical programs, and any others involved with patient’s care and approved by the patient to ensure effective coordination of services and full understanding and execution of the care plan.
  • Complete at least 20 minutes care management/coordination time each calendar month through telephonic, portal, email/messaging communications.
  • Review preventative care needs and follow up to ensure timely completion of all recommended preventative care services
  • Performs CCM services and completes systematic assessment of the patient’s medical, functional, cultural, and psychosocial needs
  • Medication reconciliation with review of adherence and potential interactions and oversight of patient self-management of medications
  • Manage escalations as appropriate/needed for care plan oversight, high priority/risk patient situations, patient education and chronic illness support outside of scope of Chronic Care Management Coordinators
  • Establishes relationships with patients and their families as needed to determine and facilitate the provision of services needed.
  • Intervenes to provide a self-management action plan of care, which utilizes appropriate resources across the continuum.
  • Follows standards of work and consistently maintains department established caseloads and timeframes for monthly chronic care management billing.
  • Maintains documentation standards in conjunction with policy and procedures to ensure appropriate provider billing.
  • Provides consultation and education to the client/family and other health care members as needed.
  • Participates in Care Management meetings, committees, and educational programs sponsored by SHCN Services, Steward Hospitals, providers and health plans as assigned.
  • Reviews appropriate reports to identify claims and process issues for reconciliation, cost-effectiveness, and outcomes.
  • Evaluates processes, identifies problems, and proposes improvement strategies to enhance the delivery of care for patients throughout continuum of care.
  • Escalates any barriers to positive outcomes to supervisor and/or manager same day
  • Participates in the refinement of and development of new standards of work.
  • Maintains awareness of key performance indicators/metrics and manages caseload through appropriate management of medical expenses. Coordinates interventions to prevent adverse events such as ED visits, hospital admissions, and readmission
  • Understands and adheres to all health plan and regulatory guidelines including NCQA/CMS/URAC/ERISA.
  • Maintains and respects patient confidentiality according to SHCN HIPAA policy and procedures.
  • Performs other functions as assigned.

Education / Experience / Other Requirements

Education:

  • Bachelor’s degree required; Master’s degree preferred.
  • Licensed Nurse Practitioner, Licensed Registered Nurse, or Bachelors in Nursing Degree or high; ability to obtain multi-state licenses as necessary
  • Certification in Case Management (CCM) strongly preferred.

Years of Experience:

  • 3 or more years of acute medical/surgical experience plus three or more years of Case Management experience. Experience with patients with long term services and supports preferred

Specialized Knowledge:

  • Understanding of the health care delivery setting.
  • Demonstrates ability to apply principles of critical thinking.
  • Knowledge of managed care principles and physician practice.
  • Knowledge of case management, utilization management, and referral management.
  • Demonstrates knowledge of managed care concepts for various health plan and capitated programs.
  • Collaborates with multiple providers to provide quality and cost-effective care for risk members.
  • Maintains information in a confidential manner according to policy.

Steward Health Care is an Equal Employment Opportunity (EEO) employer. Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.


Additional Information

Steward Health Care Network is taking additional, necessary preparations to ensure patients can receive compassionate care in a safe, carefully managed environment – with confidence and without fear.

Our Safe and Ready program consists of a rigorous [three-point] standard ensuring patient safety, confidence and convenience:

  1. Any COVID-19 related care takes place in designated areas away from other patients and their families.
  2. A stringent cleaning policy has been implemented throughout our facilities.
  3. A strictly controlled visitor and masking policy is required for patient and colleague safety.

You can rest assured that we have made the necessary preparations to provide care in a safe, controlled and professional way.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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