Geriatrics RN Care Mgr MHCP

The Geriatrics RN Care Manager is responsible for the coordination and delivery of patient care related to Complex Home Bound older adults in the MedStar Health Geriatrics. The Geriatrics RN Care Manager works with limited guidance in the coordination of care directed by the licensed independent providers of the HBPC team. The Geriatrics RN Care Manager is also responsible for monitoring critical systems reporting and following up after acute hospital utilization events, and coordinating appropriate care, post utilization event in coordination with the interdisciplinary team. The Geriatrics RN Care Manager has primary responsibility for monitoring key quality measures for the practice identified by the practice leadership and in concert with identified alternative pay model programs. As directed by independent licensed providers, the Geriatrics RN Care Manager may also perform routine direct patient care appropriate to the identified scope of practice, within the patient's place of residence.

Education

Bachelor's degree from an accredited School of Nursing required

Experience

1-2 years 2 years of experience as a nurse required and1-2 years Geriatric experience preferred

Licenses and Certifications

RN - Registered Nurse - State Licensure and/or Compact State Licensure Valid RN license Upon Hire required

Knowledge, Skills, and Abilities

Exceptional organizational, problem-solving and time management skills.Working knowledge of regulatory guidelines and accreditation standards.Ability to use a computer and other software tools for population health management and completion of clinical documentation.Ability to work independently and as part of a team.Strong interpersonal skills both in person and over the phone, including verbal and written communication.Conducts functional assessment by phone to screen new patient eligibility for MedStar House Call Program. Once approved for the program, provides education to patient, family, and care members to discuss goals of care as determined by the providers.Conducts appropriate patient education either by phone or in person, in accordance with the care plan developed as part of the interdisciplinary team. Conducts appropriate post utilization event follow-ups, care coordination and patient education.Reviews all patient intake documentation for completion, confirms information as appropriate and ensures all documentation is appropriately uploaded in the electronic Health Record.Monitors and reports on identified organizational quality measures to include reporting to external agencies as required for participation within identified special programs or reporting. Ensures that quality measure performance data is routinely reported to assigned practice providers to facilitate improvements in the quality of care. Monitors patient census for department for utilization events using multiple electronic health record systems.Contributes to the achievement of established department goals and objectives and adheres to company and department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulation.Performs routine direct patient care of home bound patients within the RN scope of practice to include but not limited to collection of patient testing specimens (blood, urine, or other), provision of routine vaccinations (Flu, COVID, others as directed).Leads the weekly MHCP meeting. Reviews high risk patients for appropriate care; may require use of various telehealth tools. Triages all clinical calls routed from the MHCP Care Coordinators. Assesses and determines urgency of request before routing to appropriate clinicianOrders medical and office supplies by contacting approved vendors to maintain appropriate inventory levels. Oversees and reports on skilled care coordination of patients in conjunction with MHCP Care CoordinatorsParticipates in multidisciplinary quality and service improvement teams as appropriate. Participates in meetings, serves on committees and represents the department and hospital/facility in community outreach efforts as appropriateCoordinates with external agencies for the provision of routine Medical DME and other community assistance for home bound older adults assigned to the program.