RN CARE MANAGER for Solid Tumor 1.0FTE 4 X 10 Hour days







PURPOSE OF POSITION: To facilitate and manage Care coordination and case management across the continuum of care for CCHMC patients. Working within a collaborative framework, insures the effective and efficient coordination and management of care to all patients within his/her caseload. This individual works to ensure that patients move along the health care continuum, promoting quality care, through appropriate, cost-effective interventions while maintaining close contact with patients, families, care providers, payers, and community resources.

·Compliance - Patient Services Staff
Sustain a working understanding of regulatory requirements and accreditation standards. Support leadership in Compliance efforts to meet and sustain the regulatory compliance efforts of the department and hospital. Be mindful and judicious in monitoring safety and departmental policies and procedures. Ensure all individual certifications and Safety College requirements are fulfilled in a timely basis. Work with department managers, nurse council and magnet representatives to identify and share safety best practices. Be mindful of CCHMCs processes and compliance with CMS standards and freely communicate safety and compliance concerns to leadership team members.
·Interprofessional Practice:
Demonstrates consistent integration of the Interprofessional Practice Model (IPM) in all aspects of practice.
·Patient Care - Age Specific and Culturally Diverse
Consistently integrates age specific and culturally diverse concepts into patient care, taking into consideration both the patient's chronological age and developmental functioning.
Conduct a comprehensive assessment of the patient's /family's health and psychosocial needs. Identify cases that meet criteria for need of care coordination (Comprehensive needs assessment). Stratifies patients to match client needs to the most cost effective model of care coordination. Meets each new patient within the caseload, introduces self and explains the Care Manager Role. Identifies the patient's support system and financial situation and initiates referrals to Social Work as needed.
Planning with the client, family or caregiver, the primary care, quality, and cost effective outcomes. Working with the patient/family, establishes treatment goals that meet the patient's healthcare and safety needs. Integrates patient/family decisions and choice into the planning process. Coordinates the plan of care and maintains documentation of case updates and discussion/events involving individuals responsible for patient welfare (e.g. family, providers, and care team members). Identifies the need for patient/family team meeting, participates in the meeting and documents the outcomes. Proactively identifies hospital clinical services needed by the patient. Reassess plan of care and adjusts plan according to patient needs.
Facilitates communication and coordination between members of the health care team (including the medical home and community services), involving the client in the decision-making process in order to minimize fragmentation in the services. Attends and leads the care coordination rounds, setting priorities and sticking to time frames (inpatient). Insures that key components of the plan of care and/or patient needs are communicated to subsequent care providers, both ambulatory and inpatient. Ensures the health care team integrates multiple sources of health care information and communicates this summary, thereby building caregiver skills and fostering relationships between the health care team and families. Demonstrates an understanding of legal and regulatory issues (HIPPA, EMTALA, regulatory agencies, CMS, legal P&P) impacting the care delivery and reimbursement process. Negotiates and advocates for the patient for services and resources needed. Provides patient/family education regarding post-acute services, community resources or other as needs identified. Creates an environment to support patient safety by integrating patient safety goals into daily practice based of the patient's age and the population served.
Monitor the patient's progress in achieving the goals, objectives, and expected outcomes of the plan at specified time frames. Monitors patients and health care providers to ensure quality and completion of services. Utilizes Critical Pathways and /or Clinical Guidelines to monitor patient progress toward health. Follows through on the status of key diagnostic and treatment tests and procedures to insure continued progression. Interacts with involved departments to negotiate and expedite scheduling and completion of tests and procedures. Identifies, documents and communicates barriers to the plan of care to the healthcare team. Serves as the contact person for and works collaboratively with Social Work to manage resource usage.
Evaluate the timeliness and availability of treatments and services, and adjusting level of service according to changing needs. Evaluate actual patient outcomes in relation to expected outcomes. Identifies quality improvement opportunities and consistent issues with smooth care progression and communicates them to the unit's management team, providing supporting data when possible. Participates in the management of metrics (outcomes, value, and experience) across the continuum of care.
Leads in outcomes based practice. Leads in the development of processes and system to measure/monitor practice. Guides healthcare team in delivery of appropriate healthcare services. Collaborate with appropriate parties to plan, implement, and/or evaluate services. Assumes accountability for facilitating patient's plan of care. Contributes to an overall team effort and accomplishment of goals. Serves as a resource for other members of the health care team. Participates in departmental education. Identifies own practice abilities and limitations and obtains instruction and supervision as necessary. This includes seeking education for self-development. Demonstrates adherence to the Code of Ethics for profession and according to system policy. Demonstrates ability to hold self and other providers accountable. Understands, applies and supports departmental/hospital policies, procedures and standards. Monitors email, phone messages and responds in a timely manner.
Implementing the agreed upon plan of care. Provides self-management support to high risk/complex patients and families. Utilizes collaborative communication skills to establish a working partnership with the patient/family, treatment team, and community resources/providers. Educates the client, the family or care-giver and members of the health care delivery team about treatment options. Empowers the client to problem-solve by exploring options of care when available and alternative plans, when necessary, to achieve desired outcomes. Encourages the appropriate use of health care services and strives to improve quality of care and maintain cost effectiveness on a case by case basis. Support and facilitate all care transitions from inpatient to outpatient, practice to practice and from pediatric to adult systems of care.

Skills & Competencies
·Development - Advanced
Possess in-depth knowledge of growth and development
·Family-centered care
Understands and support family-centered care
·Improvement Orientation
Ability and motivation to promote continuing improvement and education
·Diversity Appreciation
Understanding and showing respect and appreciation for the uniqueness of all individuals; leveraging differences in others' perspectives and ideas; appreciating cultural differences and adjusting one's approach to successfully integrate with others who are different from oneself
·Decisive Leadership
Taking responsibility for guiding others' actions and providing direction to a group; stepping forward to take the lead in addressing difficult issues and making tough judgment calls
·Professional Demeanor
Demonstrates an independent work initiative, sound judgment, diplomacy, tact and professional demeanor
·Problem Solving
Ability to independently work through details of a problem to reach a positive solution
·Research Methods - Basic
Working knowledge of research methods including measurement, data collection and validity issues
·Communication - Advanced
Excellent verbal, written and interpersonal communication skills.

·Bachelor of Science Nursing
·5 years related experience
·Registered Nurse License

·Master of Nursing
·Case Management - Nursing