Hospice RN, Care Manager
Steward Health Care Network (SHCN) takes pride in its community-based care model, which drives value-added tools and services to our communities, patients, physicians, and hospitals across the continuum of care. In addition, Steward Health Care Network promotes care coordination and collaboration within the network in order to provide high-quality, efficient care to patients. With Steward in the community, all residents can be sure that there is a world-class doctor close to where they live.
The network is also responsible for the implementation and execution of our managed care contracts, medical management services, quality improvement programs, data analysis, and information services.
Position Purpose: The Hospice Care Manager is responsible for ensuring that Steward’s ACO risk members are highly coordinated with high quality and cost-efficient outcomes through a palliative or hospice benefit as clinically indicated. The Hospice Care Manager is seen as a subject matter expert in hospice, palliative, and end of life care and the benefits that members could receive under a payor. The position works closely with all Steward lines of business such as, but not limited to hospitals, medical groups, affiliates, technology partners, and post-acute care partners. The Hospice Care Manager is tasked with ensuring that care coordination processes and procedures are visible throughout the network to ensure high quality transitions for the right patient at the right time.
- Implements value-based strategy within Steward Hospitals, focused on high quality, cost- efficient care, including but not limited to:
- Patient identification
- Performs patient centered standardized assessments including SDOH barriers and readmission risk
- Participates in multidisciplinary rounds
- Coordinates care across the continuum – example daily huddles with PAC partners
- Patient (and caregiver/family) education
- Discharge disposition planning and implementation
- Refers member beneficiaries to appropriate SHCN Care Management Programs, provides warm handoff
- Develops strong working relationships with key hospital personnel and post-acute care partners
- Uses technology, data, and clinical expertise to drive program performance communicating with key internal and external stakeholders to assist in continually improving clinical care and performance using best practices
- Meets regularly with internal / external staff to review data and develop strategies that drive continuous improvement
- Works with management and is responsible for monthly performance targets based on real time metrics as well as claims-based data
- Understands and can articulate the value of the Steward Network to patients and families while maintaining a patient's right to choose
- Assists key stakeholders in implementing care via partnered and preferred agencies
- Helps identify ACO patients appropriate for hospice referrals and completion of screening assessments to facilitate transition. Ensures documentation of activities is captured in the appropriate system(s)
- Provides clinical guidance and counseling to patients and families to assist their decision about hospice services
- Cooperates and an integral member in further developing and improving performance through data and evidence-based practice
- Communicates early and often with Providers/PCP to discuss appropriateness of hospice services
- Uses data to identify potential patients for screenings
- Demonstrates professionalism that creates and fosters a culture of continuous improvement in the department
- Performs all job functions in compliance with applicable federal, state, local, and company policies and procedures
- Travel throughout the SHCN network for meetings with internal and external stakeholders as appropriate
- Other duties as assigned
Education / Experience / Other Requirements
- Minimum 4-year degree
Years of Experience:
- Minimum two to five years’ experience in hospice role
Work Related Experience:
- Demonstrated ability to supervise and manage staff
- Knowledge of hospice governmental rules and regulations and ACHC standards
- Helping promote the hospice concept and growing programs
- Excellent critical-thinking, observation, written /verbal skills, problem-solving, and analytical skills
- Ability to lead and motivate others to execute a plan in a rapidly changing environment
- Ability to work collaboratively with health care professionals at all levels to achieve established goals and improve quality outcomes.
- Strong current working knowledge of hospice; knowledge of Accountable Care Organization (ACO) desirable
- Knowledge of leading practice in clinical care and payer requirements.
- Familiarity with the compliance and regulatory standards governing health plans and patient care including NCQA, URAC, federal, state, and other regulatory requirements.
- Current State RN license
- Valid driver’s license an insured vehicle in proper working order for local travel
- Ability to use Microsoft Office tools including Word PowerPoint, and Excel, EHR
This position is subject to the COVID-19 Vaccination Policy for Steward Health Care Workforce. Employees in this position will be required to provide adequate proof of vaccination for COVID-19 by an FDA-approved vaccine prior to starting work. Steward will consider requests for exemptions from this vaccine requirement on the basis of medical condition or sincerely held religious belief in accordance with applicable Federal laws.
Steward Health Care is an Equal Employment Opportunity (EEO) employer. Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.
Steward Health Care Network is taking additional, necessary preparations to ensure patients can receive compassionate care in a safe, carefully managed environment – with confidence and without fear.
Our Safe and Ready program consists of a rigorous [three-point] standard ensuring patient safety, confidence and convenience:
- Any COVID-19 related care takes place in designated areas away from other patients and their families.
- A stringent cleaning policy has been implemented throughout our facilities.
- A strictly controlled visitor and masking policy is required for patient and colleague safety.
You can rest assured that we have made the necessary preparations to provide care in a safe, controlled and professional way.