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Job Summary

The RN-Continuum of Care Manager Peds is a professional nurse who has clinical experience with medically complex children and families. The nurse manages targeted pediatric populations to achieve efficient and effective care delivery through adherence to Case Management standards as outlined by the Case Management Society of America. The nurse is accountable and responsible for direct and indirect patient care across the care continuum, including inpatient, ambulatory, post-acute and patient home settings. The nurse ensures continuity of care through defined, evidence based methods, including but not limited to medication reconciliation, self-management plans, engagement and education of the patient and/or caregivers, referrals and other interventions. Provides support/guidance/assistance to other staff in the management of designated populations. Develops care plans and collaborates with other care team members to address gaps in care. Promotes and facilitates improved clinical outcomes and patient satisfaction as well as efficient use of resources.

Accountabilities

Facilitation of Pediatric Patient Centered Care

1. Utilizes the nursing process to coordinate the care of an identified population of pediatric patients throughout the healthcare continuum.

2. Performs complete assessment of patient's current health status including barriers and gaps in care.

3. Develops a plan of care and self management plan to meet the needs of the patient and improve clinical outcomes and utilization patterns.

4. Coordinates patient and family participation in the development and implementation of the plans.

5. Coordinates patient/family education to meet goals.

6. Performs home visits as necessary to evaluate possible barriers to the progression of goals. 35%

Interdisciplinary Practice

1. Functions as part of the interdisciplinary team across the continuum including acute, post acute and home settings. Regularly meets with the team to develop a comprehensive plan of care based on the needs of the patient and family. Evaluates and modifies the plan of care as needed.

2. Functions as a resource to the community in areas of care coordination and utilization expertise.

3. Acts as liaison for families and external agencies and individuals providing services to specific families. Facilitates referrals to other disciplines and internal and community bases programs as appropriate to improve outcomes. 35%

Evidence Based Care

1. Utilizes and incorporates knowledge of efficiency and effectiveness indicators (example-PQRS, NCQA, URAC and HEDIS) when coordinating and facilitating a Plan of Care.

2. Increase knowledge of best practices and clinical standards of care and incorporates knowledge into practice. 20%

Measurements and Reporting

1. Documents in the medical record an on team tools, accurately reflecting collaborative care planning, interventions and evaluation against defined targets and goals. 10%

Work Shift

Day (United States of America)

Location

Richland

Facility

7002 Value-Based Care and Network Services

Department

70028455 Care Transformation

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