RN Supervisor Case Management

Company: Landmark Health
Location: Buffalo
Posted on: November 22, 2020

Job Description:

Do you want to make a difference in healthcare?

Landmark Health was created to transform how healthcare is delivered to the most medically vulnerable members in our community.  Our medical group provides home-based medical care to chronically ill patients, many of whom are frail, elderly and ill-equipped to navigate our overwhelming healthcare system.

Because many of our patients are frail and elderly, we deliver care primarily in the comfort of their home. Our Program is also offered to eligible patients  at no incremental financial cost   to them . We are not a fee-for-service practice; we benefit economically only if we deliver high-quality patient outcomes and satisfaction. As a result, our clinical teams can spend quality-time caring for a smaller number of patients, giving all patients the space, respect, compassion and care they deserve.

Our model is finding success throughout the country; we are now the nation’s largest risk-based, in-home medical group, with operations in six markets and four states across the country.

At Landmark, our interdisciplinary teams collaboratively manage our complex patient panels. These teams are led by Physicians, Nurse Practitioners, and Physician Assistants, with supporting care provided by RN Nurse Care Managers, Social Workers, Pharmacists, Behavioral Health and other employed team members.

The Clinical Nurse Supervisor   is responsible, as part of the Market Leadership and care teams, for the overall patient Care Management process. The position reports to the Health Services Director and provides oversight, guidance and support for the processes related to the development, implementation and outcomes of member care plan as developed through clinician, CM and allied clinical support evaluation and physical risk assessment.  The position provides support for the day to day operations including scheduling, outreach, and assignments.  Working with the Health Services Director, their role would be to be the main contact for health plan referrals, inpatient notifications, interdisciplinary team and care coordination.  The position is a system super user and is involved with training and oversight of the new hires and ongoing staff.  The Clinical Nurse Supervisor, as part of the leadership team, facilitates relationships in the community with providers, health plans, vendors, facilities and community organizations.

Provide operational support for the Health Services Director and Market Leadership team

Interface/collaborate with contracted health plan contacts on patients referred to Landmark programs.

Assist with strategy and process development, and implementation, including measurement of outcomes

Verify eligibility for Landmark program referrals, community referrals as well as internal referrals through review of cohort lists and collaboration with health plan contacts

Outreach and follow cohort patients admitted to hospitals for admission to Landmark programs and facilitate post discharge follow-up

Discuss with patient, family and extended decision makers the benefits of participation with Landmark programs post hospitalization

Open case management cases in Essette for case management referrals; and assigns cases to NCMS and providers based on assigned territory

Attend and actively participate in contracted health plan IDT, Clinical Operations, JOC’s and other operational meetings as required

Act as super-user and trainer for Essette, and CRM and other systems

Working with the corporate Operations team, assures documentation is completed by providers and reported up to HSD

Visit patients in hospital/SAR who are not yet enrolled and those that are to assure a smooth transition home

Monitor Daily Pulse Report and other performance and operational reporting to take appropriate action based on the data

Schedule Urgent visits for providers from on-call and during business hours, including juggling the schedules

Triage phone calls that come into office to ensure appropriate disposition and action

Triage and take appropriate action regarding warm transfer calls from Outreach

Maintain health plan referral Logs

Maintain patient Hospitalized/SAR log book and/or electronic tracking systems

Maintain weekly IDT Stat Sheet, minutes, sign in sheets and log book

Lead weekly IDT meetings

Email daily the list of new patients to provider and NCM

Actively involved with training of new NCMs and Providers

Support and execute corporate initiatives

Reconcile provider’s schedules and make appropriate corrections

Open new cases in Essette for NCMs

Meet with families in facilities and at home as needed to discuss Landmark programs

Represent Landmark at provider, vendor, facility and health plan meetings as assigned/requested

Collaborate with Office Manager for provider and NCM medical supply needs

Oversee the CMA process for scheduling of maintenance visits using the maintenance tracker report

Maintain staff PTO calendar

Maintain On call schedules/calendars for Providers and NCM's

Collaborate with SAR/ALF facilities for appointment dates for post discharge and updates for those already enrolled.

Maintain Provider schedules for meetings, PTO etc.

Maintain quality of services through audits and education

Participate in and lead CQI teams

Serve as a resource to the entire care delivery team

Identification, tracking, resolving, responding to and reporting any quality of care issues

Maintain HIPAA compliance as it relates to member care

Participate in interviewing, hiring training, evaluating and disciplining of IDT staff

Other duties as assigned

Current RN License, BSN preferred

5+ years of clinical practice in a hospital, clinic, home care, or nursing home setting

2-3 years of increasing supervisory or management experience in a health care setting

Case management experience required

Disease and utilization management experience useful

Physician office experience helpful

Keywords: Landmark Health, Buffalo , RN Supervisor Case Management, Other , Buffalo, New York