Quantitative Risk Manager Jobs in Chesapeake Beach, MD

Position Objective:  

The Case Manager works under the direction of the clinical director of care management, providing coordination of care for patients at Luminis Health to support safe, seamless, timely transitions across the continuum.  Utilizing a collaborative process, will identify (using quantitative and qualitative methods), assess, plan, implement and evaluate the options and services required to meet an individual's health and health related needs, including social- determinants that affect ones' overall wellbeing. Promotes the right resources, at the right time and at the right level of care and is responsible for engaging and supporting patients that are in need of care management services; is able to determine, using evidence based guidelines, the correct initial and ongoing level of care for patients and is able to submit appropriate denial review for Medicare, Medicaid and commercial insurers.

Essential Job Duties:

 Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 1. Identifies and prioritizes patient in need of care management services, using a holistic approach inclusive of biopsychosocial, functional, cultural, spiritual, and financial factors; uses a multi discoplinary approach to assess/plan for care needs.

2. Identifies and implements strategies such as motivational interviewing to promote patient engagement, self-care, treatment adherence, and optimal levels of health and well-being.

3.  Utilizes evidenced based guidelines (such as InterQual or other agreed upon evidenced based guidelines) to promote quality care, decrease variation and mitigate waste. Verifies appropriate level of care; enters clinical review and authorized days in Epic; documents actions to avoid denied days; refers cases to Physcian Advisor as appropriate.

4. Manages observation stay patients assertively and ensures timely testing,  treatment and conversion to inpatient status or discharge.  

5. Develops and coordinates transition plans for patients transitioned to home with home health, community care coordination program, Hospice or Palliative care, home infusion and routine sub-acute and skilled post-acute providers; completes all necessary documentation and necessary handovers.  Involves and prepares patients and families for transition from the ED, Peds, Clatanoff or Observation unit as indicated. 

6. Maintains clear and concise documentation in each patient record to reflect physical and functional limitations, psychosocial characteristics, educational needs of patient & family, family/social support systems, financial, economic, and transition needs. Initiates referrals to disciplines as indicated.

7. Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management. 

8. Identifies potential or current patient situations which require referral to other members of the health care team such as infection control, risk management, or quality management.  Assures plan of care is adjusted as appropriate and that follow-up occurs.  Keep leadership abreast of potential issues.

9. Utilizes all risk and predictive analytic tools such as the readmission risk tool.  Applies tailored interventions to mitigate potential barriers or risk, prolonged unnecessary hospitalization and readmission prevention.   

10. Maintains compliance with all regulatory standards (CMS, commercial insurers etc)

Educational/Experience Requirements:

BSN or ADN with equivalent experience.  BSN must be achieved within 5 years of start date in the role

Three years of experience in a clinical setting, ambulatory or post-acute.

Care coordination experience preferred.    

Licensure/Certification:

Current  licensure as a registered nurse by the Maryland Board of Nursing.     

Working Conditions, Equipment, Physical Demands:

There is reasonable expectation that employees in this position will be exposed to blood-borne pathogens.

Physical Demands -  Medium work

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position.  This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.