Ohio's Hospice

Manager

• Plans and delivers care to patients utilizing the nursing process of assessment, planning, interventions, implementation, and evaluation
• Effectively interacts with patients, families, and other interdisciplinary team members while maintaining standards of professional nursing

RN Care Manager

• The Pure Healthcare Care Manager will develop comprehensive, person-centered care plans for every member, with a focus on ensuring timely and appropriate access to care and the skillful coordination of a broad array of medical and social services.
• This position affords the opportunity to work with individuals, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care from acute care across the continuum.
• The Care Manager is the key to ensuring a collaborative and proactive approach to support the individual and caregiver in the management chronic medical conditions.
• Assists individuals and their families with personal or environmental needs through care coordination, navigating care systems, planning for care transitions, or discharge to next level of care.
• Ensures and facilitates access to community resources, such as transportation, insurance/supplemental income sources, care giving, food, etc.
• Facilitates individual and family meetings for the purposes of goal setting, advance care planning, coordination of community supports, and plan of care development, based on the individual's needs, values and preferences.
• Collaborates with other PHC and Ohio’s Hospice divisions as appropriate to improve communication of needs; if to outpatient support center, coordinates plan of care for follow up and instructions on AVS; if hospice care is desired, initiates referral process.
• Coordinates plan of care between settings (home, hospital/inpatient, outpatient services, etc) to ensure continuity of care and ability to obtain necessary medical treatment, equipment, and physical/emotional needs.
• Documents assessment, plan and interactions with individual, family, community resources, hospital or facility staff, and physicians and establishes/builds account in electronic medical record.
• Participates in the development of processes to improve the clinical experience for referral sources, individuals/families, care management teams, etc. across the continuum of care.
• Regularly attends IDT meetings or other multidisciplinary team meetings based on Individual/family needs or organizational needs.
• Fosters collaborative working relationships within division, organization, hospitals, and community facilities and/or with groups with whom we are engaged.
• Attendance at division meetings 80%; accountability for 100% of information provided via minutes.
• Annual education completed by deadline to ensure staff has the information and tools to complete their job satisfactorily and meet regulatory compliance.
• Adheres to all applicable federal and state regulations, including HIPAA, compliance, and employment regulations.
• Maintains strong knowledge of and adherence to NCQA standards for Complex Care Management.