The ConcertoCare Case Manager coordinates all aspects of a patient’s care (medical, behavioral, functional, and social) and serves as a patient advocate across the continuum of care in partnership with the patient’s providers and extended care team. This is a unique Case Management role that is intimately integrated with a larger care team. This role requires a high level of interaction to successfully engage patients and foster positive, trusting relationships to help them achieve their goals. The ideal Case Manager has excellent communication skills, takes initiative, works well with other members of the care team, and creatively problem- solves to address a patient’s needs holistically. This position is part of the Population Health Team, reports to the Vice President of Case Management, and works closely with other Population Health team members as well as market -based care teams.

This is an ideal position for a registered nurse who seeks an opportunity to contribute to the health and well-being being of highly complex patients, enjoys a collaborative multidisciplinary team-based approach to care, and is excited to engage in developing and nurturing our innovative, value-based clinical model focused on caring for patients with complex and social support needs that the current health system does not serve well.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Conduct initial intake calls as well as scheduled and urgent patient outreach based on individual patient’s needs and risk level to review and update the care plan, monitor progress, ensure needs are met, and identify new areas of concern.
• Provide ongoing care coordination for an assigned panel of complex patients.
• Conduct needs assessments and develop plans of care in partnership with the rest of the patient’s care team.
• Ensure care is coordinated, patient-centered, and aligned with the needs and wishes of the patient.
• Support patients during care transitions, including outreach and assessment during and post hospitalization to ensure discharge needs are addressed, to facilitate provider follow-up, and to perform medication reconciliation.
• Identify and implement interventions and collaborate closely with ConcertoCare’s multidisciplinary team (providers, Director of Clinical Care, market nurses, social work, behavioral health, and clinical pharmacy), external providers, and social service organizations to: (1) address gaps in care, (2) mitigate the risk of inpatient admissions, readmissions, emergency room visits and movement to an institutional setting, (3) and keep patients safely living in their desired and appropriate home environment.
• Identify and verify appropriate utilization of resources across the continuum of care.
• Actively participate in interdisciplinary care team huddles, and other clinical meetings.
• Participate in quality improvement and evaluation processes.
• Adhere to compliance policies, procedures, and standards of conduct including all applicable laws and regulations.
• Other duties as assigned.

QUALIFICATIONS

• Current RN License in good standing in the state of Rhode Island required.
• Reside in Rhode Island or within a commutable distance.
• Minimum associate degree in nursing required, bachelor's degree preferred
• Minimum of 3 years’ experience working in a clinical setting, with at least one year of case management experience in home health care, ambulatory care, community public health, and/or the insurance setting.
• Certified Case Manager (CCM) certification or commitment to complete when eligible
• Geriatric care experience highly desired
• 1 year discharge planning, utilization management, case management, performance improvement, and/or managed care preferred.
• Knowledge of Medicare and Medicaid regulations and insurance benefits preferred
• Strong clinical skills and ability to implement evidenced-based care.
• Ability to manage patient complexity and multiple clients with diverse needs
• Demonstrated ability to triage patient reported symptoms and issues that require escalation to our field-based team and apply critical thinking skills in unexpected circumstances.
• Ability to communicate effectively in writing and verbally.
• Demonstrated ability to perform multiple concurrent tasks with minimal supervision and meet deadlines.
• Ability to work in a fast paced, dynamic environment and work well with others on a team.
• Proficient computer skills including Microsoft Office Suite (Outlook, Excel, PowerPoint, Word) as well as clinical systems/ EMR competency
• Knowledge and ability to navigate internet-based tools and applications, and proficient in computer documentation
• Demonstrates a high level of professionalism.

Base Salary/ Wage Range $100,000 to $120,000 plus annual bonus. Compensation for the role is commensurate with the candidate’s qualifications, skills, competencies, and experience and may fall outside of the range shown. ConcertoCare offers a competitive total rewards package, which includes full healthcare coverage, a 401K with match, and a broad range of other health, wellness, and financial benefits.

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status. ConcertoCare is an Alcohol/Drug/Smoke-Free Workplace