Post-Acute Care Manager – Population Health
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Job Description
Post-Acute Care Manager at Bon Secours Mercy Health coordinating and managing care for patients discharged to post-acute facilities. Collaborating with interdisciplinary teams and ensuring safe discharge plans.
Responsibilities:
- Provide care to patients discharged to post-acute facilities and maintain a caseload according to productivity standards
- Perform and coordinate work with the patient, family or support members, inpatient case management team, and interdisciplinary care team members
- Communicate regularly on post-acute care of specific patients, as well as population level care and performance
- Run daily reports for transitions of care, make assignments, and review goals of care
- Communicate at minimum weekly with skilled nursing facilities to encourage progression of care within an appropriate length of stay
- Evaluate effectiveness of care plan with Interdisciplinary Team (IDT)
- Conduct comprehensive assessments and complete required documentation
- Perform patient outreach according to established protocols and document in electronic medical record
- Coordinate referrals and transitions of care from one provider to another or from one care setting to another
- Provide Patient and Family or Caregiver education
- Refer to appropriate next level of care and discharge planning with facility, patient, and family or caregiver
- Conduct monthly meetings with high volume facilities on overall performance, quality, and readmissions
Requirements:
- Current RN License in the state in which they are working or covered by compact (required)
- Certification for care management (preferred)
- Bachelors of Science, Nursing (BSN) (preferred)
- 2 years of nursing experience (required)
- 1 year of experience in skilled nursing settings (preferred)
- EPIC Electronic Health Record (preferred)
Benefits:
- Competitive pay, incentives, referral bonuses and 403(b) with employer contributions (when eligible)
- Medical, dental, vision, prescription coverage, HSA/FSA options, life insurances, mental health resources and discounts
- Paid time off, parental and FMLA leave, shot- and long-term disability, backup care for children and elders
- Tuition assistance, professional development and continuing education support
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