Provide care coordination and discharge planning for HUSKY Health members in rural areas to prevent hospital readmissions. This involves conducting face-to-face inpatient assessments and collaborating with healthcare providers to ensure safe transitions of care.
Requirements summary
Requires a current, unrestricted Registered Nurse (RN) license and a minimum of 2 years of direct clinical care experience. An Associate's degree is required, though a Bachelor's degree in Nursing is preferred.
Community Health Network of Connecticut, Inc. (CHNCT) is currently seeking an Inpatient Discharge Care Manager – Rural Health.
Qualified applicants should reside in one of the following areas
Litchfield County, CT
Windham County, CT
New London County, CT
The Rural Health Transformation (RHT) Program is a federal grant that empowers states to strengthen rural communities across America by improving healthcare access, quality, and outcomes by transforming the healthcare delivery ecosystem.
Primary Responsibilities
Under the direction of the Care Management (CM) Manager of Rural Health Transformation, provide care coordination support for eligible HUSKY Health members residing in rural areas.
Collaborates with the hospitals, primary care providers, home health agencies, members, caregivers, and the CHNCT care team to identify and address clinical needs and access barriers that may contribute to readmissions.
Meets with members while they are inpatient to assess factors potentially impacting a safe transition of care, including physical needs, cognitive limitations, psychosocial needs, and gaps in primary care or community-based support services.
Provides health education and information on available HUSKY Health and community resources to members.
Collaborates with the health care team to develop an outpatient strategy that includes proper post-acute follow up care as part of a comprehensive discharge plan.
Tasks Performed
Completes face-to-face visits with members while in the hospital.
Conducts comprehensive assessments through member interviews and review of available clinical information including member history and current presentation to identify needs and develop multidisciplinary interventions.
Explores and coordinates appropriate alternatives to acute care and communicates recommendations to attending physician, member/authorized representatives, and hospital care coordinator to facilitate appropriate and timely action.
Discusses anticipated discharge plans with the inpatient providers/PCP, CHNCT care team and outpatient providers.
Initiates referrals as necessary.
Benefits
Tuition reimbursement
Flexible spending accounts
Group term life insurance
Wellness program
Company holidays
Health savings accounts
Continuing education opportunities
Vision coverage options
Dental coverage options
Medical coverage options
Voluntary accidental injury coverage
Paid-leave bank
401(k) plan with company-match and immediate vesting
Participates in internal and external collaborative meetings.
Provides cross coverage of post-discharge follow up activities for members recently discharged from the hospital or emergency department including conducting the assessment and implementing member-centric, transitions of care interventions.
Identifies and refers Quality of Care (QOC) issues to the Quality Management department.
Performs other duties as assigned.
Essential Functions
Develops and maintains collaborative relationships with internal and external constituents including hospitals/providers.
Successfully interacts with business partners.
Utilizes referral criteria for triage of members to appropriate CHNCT departments.
Collaborates to review members with potential ED over utilization risks and readmissions and works with the care team to formulate plans to address.
Maintains knowledge of CHNCT programs, other ASO and community programs, vendors, and covered benefits for the Medicaid programs.
Desired Education: Two to four years post-secondary schooling
Minimum 2 years direct clinical care experience as an RN is required.
Other Qualifications
Strong verbal and written communication skills. Excellent organizational skills, ability to manage multiple priorities concurrently. Demonstrates strong critical thinking and problem-solving skills. Ability to work independently and in a team environment. Uses tact and diplomacy for highly sensitive information and issues. Team player. Strong computer and keyboard skills. Flexible in covering assignments. Case Management experience preferred. Knowledge of Medicaid regulations preferred. RN license must be current and unrestricted. Current and unrestricted motor vehicle operator's license and reliable transportation.
Certifications Required: Active Registered Nurse License, State Motor Vehicle License
CHNCT Offers Great Benefits
Medical, dental and vision coverage options
Flexible spending and health savings accounts
Group term life insurance
A 401(k) plan with company-match and immediate vesting
Voluntary accidental injury coverage
Tuition reimbursement and continuing education opportunities
A generous paid-leave bank and company holidays
Wellness program
We are dedicated to having a workplace where everyone feels valued, respected, and empowered to succeed. We embrace a wide range of perspectives and backgrounds, ensuring fair treatment and opportunities for all employees. We value our team’s rich array of experiences and viewpoints, which contribute to our innovative and collaborative environment.
We are committed to providing an inclusive and accessible interview process. If you require a reasonable accommodation for your interview due to a disability. Please contact us in advance if you need an accommodation.
