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Integrated Care-Intensive Care Manager RN

Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 327-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus as well as at 10 Eskenazi Health Center sites located throughout Indianapolis.

Job Role Summary

The Intensive Care Manager, RN through home visits, serves as a coordinator of care, collaborating in tandem with other members of the Care Integration Team, physicians, nursing, interdisciplinary team, and patients/families to provide seamless and efficient services for those within their assignment. This position functions as a Care Manager, providing assessments, demonstrating problem solving and critical thinking skills, and practicing effective decision making. This position is M-F 8-4:30pm and is conducted out in our community via home visits.

Essential Functions and Responsibilities

Proactively contributes to Eskenazi's mission: Advocate, Care, Teach and Serve with special emphasis on the vulnerable population of Marion County; models Eskenazi values of Professionalism, Respect, Innovation, Development and Excellence.

Serves as a coordinator of care, collaborating with other members of the Care Integration Team, physicians, nursing, interdisciplinary team, and patients/families to provide seamless and efficient services for those within their assignment.

Provides face to face, home, or telephone visits to address patient’s needs and performs follow up calls to assigned patient population.

Monitors disease control and psycho-social indicators; works with the patient’s primary care team to ensure medications and lifestyle treatment goals are being reached.

Collaborate with patient/family, sets realistic step-by-step goals to reduce specific chronic disease and psycho-social indicators.

Serves as an integral part of the care team to mitigate long-term medical and financial risks from poorly controlled chronic diseases.

Independently functions as a Care Manager, providing assessments, demonstrating problem solving and critical thinking skills, and practicing effective decision making.

Demonstrates knowledge of pathophysiology, pharmacology and disease processes for the assigned population, and age-appropriate care.

Case Management

• Communicates with physicians, interdisciplinary team, nursing and patients/families to ensure timely patient progression through the episode or plan of care
• Resolves problems impeding diagnostic or treatment progress
• Strategize to ensure proper utilization of resources within the targeted population
• Interviews patients; collects and assesses specific information in an attempt to identify individual needs and develop a comprehensive plan of care that addresses medical, social and financial needs
• Collaborates with the Director of Ambulatory Integrated Care and Director of Inpatient Integrated Care, as well as the Physician Advisor to identify cases that require special intervention
• Actively participates in creating an action-oriented and time specific plan of care
• Ensures adherence to clinical pathways/protocols and the appropriate use of clinical tools through collaboration with physicians, interdisciplinary team, nursing, community health workers, Integrated Care Coordinators and Transition of Care staff
• Reassesses and monitor patients for change in condition warranting initiation of a clinical pathway and alteration in plan of care
• Documents processes and care plan information in medical record appropriately
• Monitors the plan of care for assigned patients and collaborates with other members of the Care Integration team for planning
• Educates physicians, interdisciplinary team, and nursing, regarding payer sources and the role this plays in transition planning
• Communicates with on-site private payer/managed care case managers
• Evaluates active funding for each patient and communicates with Financial Counseling to facilitate the initiation of appropriate funding applications
• Addresses financial barriers to healthcare/medical compliance with the patients and families when indicated

Community Outreach & Patient Engagement

• Provides education to patients/families that are adapted to their unique needs, lifestyle, and socio-economic situations
• Educates and informs patients of community resources that are located within their neighborhood community
• Advocates for vulnerable patients and participates in assessing their needs for health care services and community programs

Job Requirements

• Current Indiana licensure as a Registered Nurse required
• Three years of clinical nursing experience required

Knowledge, Skills & Abilities

• Demonstrates knowledge of the case management, patient education and care coordination process
• Demonstrates effective communication skills, knowledge of disease processes, and normal growth and development for all age groups, in order to ascertain an accurate understanding of the patient’s symptomology
• Competency in the following areas required:
• interpersonal, written/verbal communication and negotiation skills
• diplomacy, flexibility and professionalism
• cohesive networking with the interdisciplinary team