Population Health RN Inpatient Case Manager

The Population Health RN Inpatient Case Manager (PHRNICM) is responsible for
providing complex case management (CCM) to diverse groups of high-risk capitated
populations. Complex case management is defined as the coordination of care and
services for members who need help navigating the healthcare system to
facilitate the appropriate delivery of the right care and services at the right
place and time. These services are provided utilizing available resources across
a continuum of care and in collaboration with members, caregivers, medical home
providers, and ancillary health care providers. NBH utilizes a Population Health
approach to identify diverse groups and to enhance member engagement and
coordinate care delivery across populations to improve clinical outcomes. In
addition to continuum of care responsibilities this position will assist within
the inpatient case management department as needed.

Primary Job Duties

* Identify patients who are considered high risk for medical care resource
utilization by reviewing information from referrals placed in the electronic
health record (EHR). Referrals may also come through ED, Pharmacy, Hospital,
and other departmental or systems reporting.

* Conducts assessments to identify the member’s needs and develops a specific
care plan to address objectives, barriers, and goals identified during the
assessment.

* Comprehensively identify strengths and opportunities for patients, including
physical, behavioral and social support system capacities and degree of
engagement with providers.

* Follow-up with patients and providers on identified health care needs and
identify possible resources to address those concerns and/or work with care
management team to address concerns in a multi-disciplinary method.

* Facilitate and manage referrals from referral specialist, providers, and
other care management staff to ensure that identified red flags and
healthcare needs of patients are addressed.

* Provide individual consults to patients on health education issues. Develop
the health awareness of individuals, as well as groups and organizations,
empowering them to make better health choices.

* Provide specialized oversight, implementation of care plans, and education to
patients while exercising discretion and independent judgment; following
established policies and procedures.

* Identifies “at risk” individuals and applies clinical based guidelines for
development of a comprehensive plan of care. Obtains and evaluates relevant
information (medical, psychosocial, financial) utilizing interviewing
skills.  Advocates for patients and their families throughout their episode
of care. Maintains availability to patients/families as a resource to
facilitate communication among providers and to monitor services rendered.
When appropriate, meets directly with the patients and their families based
on identified needs. Collaborates with patient, family, physicians and the
interdisciplinary team to develop individualized comprehensive plans of care
and to identify needed changes to the plan throughout care continuum. 
Remains involved until the patient achieves the planned level of functional
health or closure criteria are met.

* As appropriate, coordinates/meets directly with the patient/family and the
interdisciplinary team based on identified needs.  Provides patient/family or
significant other with information about appropriate providers.

* Involve the patient and their support systems (i. e. caregiver, family, etc.)
in the decision-making process. Use proven processes to measure patient’s
understanding and acceptance of the proposed plan(s), willingness to change,
and support to maintain health behavior change. Apply teaching and learning
theories to assist patients and families with physical and emotional impact
of body changes and chronic illness.

* Document and communicate with all provider(s) and member(s) of the care team
as needed to minimize fragmented care. This will include navigating
transitions of care - generally from hospital to home or community
facilities.

* The PHRNICM will employ effective problem-solving techniques and conflict
resolution skills to provide consistent quality care to the patient.
Participates in department quality monitoring and improvement. Examples of
this might include: department quality audits, developing and delivering
training or other assigned projects.

* The PHRNICM will analyze and evaluate the effectiveness of Case Management on
quality patient outcomes, fiscal parameters, customer satisfaction and system
operations. Strategies for performance improvement will be accessed and
communicated to UM Manager and Director of Care Management as appropriate.

* Manages the care of patients through health care systems based on the
individual’s needs.  Works in collaboration with physicians and appropriate
health care providers for changes in plans as required. Advocates for the
patient and family throughout the entire episode of care. Maintains
availability to the patient/family as a resource to facilitate communication
among providers and to monitor services rendered.  Develops an individualized
comprehensive plan of care in collaboration with the physicians, Social
Services, and the interdisciplinary team. Tracks appropriate patient pathway
through identification and assignment of DRG.  Communicates with
patient/family/physician/staff the anticipated discharge date (ADD).
Proactive in communicating, assessing and reassessing patient throughout
episode of care with development of alternative discharge plans as
indicated.  Works to transition patient to next appropriate level of care,
appropriately involving Outpatient Case Management Services or other
resources. Remains involved until the patient is discharged from the hospital
and/or transfers case management function to outpatient services.

* Other duties as assigned to meet the needs of the population managed.

Interpersonal Skills and Values

Demonstrates NorthBay Health’s True North Values: Nurture Care, Own It, Respect
Relationships, Build Trust, and Hardwire Excellence. These values guide
behavior, accountability, teamwork, and commitment to high-quality patient care.

Why NorthBay Health

NorthBay Health is an independent, nonprofit health system serving the Napa,
Solano, and Yolo County regions. We are expanding access to care across our
communities through two acute-care hospitals, including a Level II Trauma Center
and a Level III NICU maternity unit, along with a cancer center, urgent care
locations, and a growing network of primary and specialty care clinics.

We provide advanced services in cardiovascular care, neuroscience, orthopedics,
surgery, and outpatient specialties. NorthBay Health is nationally recognized
for quality care, including Magnet with Distinction designation for nursing and
multiple U. S. News and World Report high performing recognitions.

We are committed to being the trusted healthcare partner of choice and offer an
environment where employees can grow, contribute meaningfully, and support the
health of our communities.

NorthBay Health Benefits Options

NorthBay Health offers a comprehensive benefits package based on established
eligibility requirements. Benefits may include medical, dental, and vision
insurance, life, disability, and long-term care coverage, paid time off
including vacation, sick leave, holidays, and bereavement, a 403(b) retirement
plan with employer match, education reimbursement for eligible roles,
professional development and training programs, Employee Assistance Program,
wellness programs, recognition programs, shift differentials, and market-based
compensation review and increases subject to approval and organizational
performance.

Compensation Structure

NorthBay Health uses a structured compensation framework. Staff-level positions
use a step-based system (Steps 1–5) based on years of directly related
experience, with Step 5 representing 20 or more years of experience in the role.
Manager level and above positions are paid a fixed annual base salary and are
eligible for a variable incentive compensation plan. Physician compensation is
structured based on specialty and role requirements.

Remote Work Disclosure

NorthBay Health is primarily an onsite organization due to the nature of
healthcare. Some roles may allow hybrid or remote work based on business needs.

Remote work is not supported in Washington, Ohio, Wyoming, North Dakota, Puerto
Rico, the U. S. Virgin Islands, or outside of the United States.

Notice to Recruitment Agencies

NorthBay Health utilizes a managed service provider (MSP) for agency
partnerships and is not currently engaging external recruiting firms outside of
established agreements. We do not accept unsolicited resumes or third-party
candidate submissions. Please do not contact NorthBay Health employees, leaders,
physicians, or hiring managers regarding recruitment or job postings.

More Information

Visit NorthBay Health Careers for recruitment FAQs
[https://www.northbay.org/careers/recruitment-faq.html] and additional
information.