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The RN Care Manager serves as a liaison among Brookdale teams, residents, families, and healthcare providers within our communities, promoting coordination, communication, and collaboration at Brookdale's HealthPlus communities. This role encompasses the identification, coordination, communication, and implementation of services essential for enhancing residents' quality of life and achieving an optimal level of wellness. Works closely with primary and specialty care providers to formulate resident-specific care plans, ensuring that the delivery of medically necessary services aligns with established care plans. Serving as a resident advocate, they actively contribute to identifying and improving service delivery, closing gaps in care, and understanding key interventions and care protocols relevant to treating residents in place.

1. Educates and explains Brookdale's care pathways as determined by individual diagnosis and healthcare needs.
2. Monitors and communicates quality performance measures, and assists with training and education of teams to ensure quality outcomes for residents. This involves effective communication and collaboration with providers and other healthcare entities, such as managed care coordinators, insurance providers, and external healthcare partners responsible for coordinating resources and supplies pertinent to resident needs.
3. Reviews the current population's medical diagnoses to identify care needs. Assists in assessing the health, functional, and psycho-social status of residents.
4. Coordinates services required to enhance optimum wellness and manage chronic conditions.
5. Collaborates with hospice, palliative, and home health services/therapy as indicated.
6. Provides advanced care planning education to residents and families/responsible parties. Helps ensure each resident has a completed Advanced Care Plan, inclusive of goals of care. Communicates with healthcare providers to ensure care delivery is consistent with the resident's Advanced Care Plan(s) Participates in collaborative care reviews (CCR) and care conferences.
7. Provides resources for residents and families to make informed decisions regarding choices in meeting healthcare needs and effectively champions the benefits of residing and receiving care and services at the community. This includes informing them about opportunities to enhance care and the benefits of an IE-SNP plan or other benefit opportunities.
8. Applies quality improvement methodology to analyze, enhance, and manage outcomes, striving to achieve quality measure goals. Collaborates with Health and Wellness Directors (HWD) to ensure compliance with service plans, while working with providers to attain value-based outcomes for our residents. This includes coordinating and communicating care for each resident.
9. Provides oversight, coordination, and family communication during resident hospitalization and rehab stays. Ensures return to the community where appropriate.
10. Communicates information promptly to the appropriate care provider regarding changes in residents' health/well-being, personal needs, risk management issues, customer service issues, and family, or outside health care provider concerns.
11. Facilitates continuity of care for those residents receiving home health care, hospice services, and other third-party healthcare-related services.
12. Completes documentation as required by Brookdale or state regulatory agencies.

This job description represents an overview of the responsibilities for the above referenced position. It is not intended to represent a comprehensive list of responsibilities. An associate should perform all duties as assigned by his/her supervisor.

Brookdale is an equal opportunity employer and a drug-free workplace.