RN, Registered Nurse Care Management Coordinator Karabots

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We strongly encourage all candidates of diverse backgrounds and lived experiences to apply.
A Brief Overview

This position is located at CHOP Karabots Primary Care Center

This is M-F hybrid no weekends or holidays at this time. We would prefer someone with Pediatric case/Care Management experience, however would consider someone who has adult experience.
The 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, may be assigned to the care of patients who receive primary care outside of the CHOP Care Network, or a specialty care disease-specific Care Management model. S/he serves as 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 resources.
What you will do

• Practice
• General Care Management responsibilities:
• Identify patients in need of Care Management and maintain a patient database.
• 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 Management interventions
• Transfer patients to higher or lower levels of Care Management support as appropriate.
• Collaborates with patient and family health care providers and agencies using a multidisciplinary and holistic approach to help the patient and family set realistic and achievable goals to achieve the desired outcomes.
• Utilizes professional and community knowledge and influence to obtain resources in the most cost-effective manner to best meet the patient's developmental, physical, psychosocial and financial needs.
• Researches, selects and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes.
• Adapts behavior as needed to the specific patient population, including but not limited to respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style.
• Outpatient Care Management responsibilities:
• Communicate regularly with PCP 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 contact.
• 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.
• Inpatient Care Management 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 services.
• 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 Management 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 to);
• Obtain and document patients’ histories.
• Perform and document physical assessments.
• Conduct telephone triage and refer patients to appropriate services.
• 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 Management program.
• Serve as an institutional expert on care coordination and transition management.
• Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops.
• Research
• Read, analyze and synthesize nursing and other scholarly articles and research studies and share knowledge with colleagues.
• With assistance, apply research findings to clinical practice.
• Seek opportunities to participate in research studies or quality improvement projects.
• Learning
• 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 practice.
• Participate in the development/presentation of education programs.
• Demonstrate health care informatics competency in order to manage patient care, outcome data and current and emerging health care technology.
• Resource Management
• Participate in promoting quality, efficient and cost-effective care.
• 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.
• Other Responsibilities
• Adheres to established departmental policies, procedures, and objectives.
• Maintains established department/hospital/system policies and procedures, directives, safety, environmental and infection control standards appropriate to this position.
• Demonstrates a courteous and professional manner through interactions with internal and external customers.
• Exemplifies a professional image in appearance, manner and presentation.
• Engages in self-performance appraisal, identifying areas of strength as well as areas for professional development.
• Performs other related duties as assigned.

Education Qualifications

• Associate's Degree Nursing Required
• Bachelor's Degree Nursing Preferred

Experience Qualifications

• At least five (5) years of nursing experience Required
• Pediatric experience Preferred
• Nursing experience with a combination of outpatient and inpatient experience Preferred
• Discharge planning or home care experience Preferred

Skills and Abilities

• Ability to complete multiple tasks and work under pressure.
• Excellent Customer Service skills, phone etiquette and communication skills.
• Ability to work independently and excellent organizational skills.
• Computer Competency
• Microsoft Office proficiency
• Navigation and basic search functions of the Internet using Internet Explorer
• Use of Outlook 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 machines
• Information 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 system
• Understanding of policies and procedures around timeliness of care, use of a clinical information system and support of safe nursing practice
• 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 references

Licenses and Certifications

• Registered Nurse (Pennsylvania) - Pennsylvania State Licensing Board - upon hire - Required or
• Nursing Temporary Practice Permit (Pennsylvania) - Pennsylvania State Licensing Board - upon hire - Required or
• Registered Nurse (New Jersey) - New Jersey State Licensing Board - upon hire - Required or
• Nursing Temporary Practice Permit (New Jersey) - New Jersey State Licensing Board - upon hire - Required and
• Basic Life Support (BLS) - issued through on organization that requires a hands-on instructor lead psychomotor skills verification (ex. American Heart Association or Red Cross). - upon hire - Required

To carry out its mission, CHOP is committed to supporting the health of our patients, families, workforce, and global community. As a condition of employment, CHOP employees who work in patient care buildings or who have patient facing responsibilities must be fully vaccinated against COVID-19 and receive an annual influenza vaccine. Learn more.
Employees may request exemptions for valid religious and medical reasons. Start dates may be delayed until candidates are immunized or exemption requests are reviewed.
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