Sisters of Providence Health System
The RN Care Manager- Bundled Payment Specialist (RN-BPS) is a professional Registered Nurse with a broad clinical knowledge base. The RN Care Manager- Bundled Payment Specialist will collaborate with the inpatient care manager for coordinating discharge plans and managing the post-acute stays and home health services for the BPCI patient for the entire episode of care. The individual will be responsible for building relationships with the BPCI partnering hospital as well as across all post-acute care settings to promote utilization of evidence-based best practices and efficient methodologies to provide safe, quality care across the health care continuum for the BPCI patient.
PRIMARY JOB RESPONSIBILITIES AND DUTIES:
Within 24 hours of BPCI patient admission, receive notice from the Hospital Case Manager for the acute stay. Coordinate with Hospital CM to gather and document all necessary clinical information to determine best discharge plan for the patient.
Maintain an accurate census of BPCI patients and document all interactions utilizing Episode Connect.
Build a collegial working relationship to efficiently manage the BPCI patient across the health care continuum to manage LOS and discharge disposition reinforcing that the patient is in the right environment at the right time; ask questions and influence decision points as needed to provide the patient with the most appropriate site of care for transition
Communicate with each patients Principle Accountable Practitioner to facilitate patients family meetings and confirm the discharge plan.
Coordinate and track all patients discharge dispositions and destinations via communication with PAC patient care team.
Utilize real-time data and Remedy generated reports to track key performance indicators and identify areas of concern.
Upon patients transfer to a Skilled Nursing Facility, Rehab or LTAC, the RN-BPS will call the CM or Social Worker assigned to the patient to discuss the case and receive report within 24 hours of transfer with goal of managing SNF LOS.
Upon transfer to a HHA, the RN-BPS will call the HHA to review the critical areas of concern that were reported at time of transfer to ensure the patients needs are being met. The RN-BPS should utilize the evidence-based guidelines per diagnosis to emphasize number of visits expected by the HHA.
The RN-BPS will provide education and encouragement to patient and family members related to the bundle episode and co-morbidities during the episode of care, as needed.
Throughout the episode, the RN-BPS will be responsible for tracking key metrics including site of service, days of utilization and readmission.
Attend BPCI work group meetings to report on success of program initiatives and processes.
REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:
Graduation from accredited School of nursing; BSN. Current Massachusetts RN license in good standing required. CCM certification preferred.
Requires a minimum of 3-5 five years experience as a registered nurse with case management experience, hospital or community based.
Knowledge of industry benchmarks as well as services provided in the post-acute health care setting.
Professional communication skills needed for all clinical interactions as well as excellent interpersonal skills/techniques needed to promote patient, family and caregiver involvement.
Approaches and responds to conflict in a constructive manner, with a focus on problem solving for a collaborative solution/resolution.
Strong attention to detail. Track record of success in the coordination of care across multiple sites.
Ability to simultaneously address and prioritize multiple projects, demands and issues.
Demonstrated ability to operate in a collaborative, shared leadership environment.
Possesses knowledge of budget processes, quality improvement, report distribution, TJC standards, state and federal regulations, six sigma and LEAN methodologies.
Solid computer and analytical skills required.