Nurse Care Manager - Post Acute Care (CST)
Skills
- Experience in telephonic care management and skilled nursing facility care.
- Knowledge of value-based care models and strategies to reduce hospital readmissions.
- Strong understanding of skilled nursing facility operations and regulations.
- Excellent collaboration and communication skills.
- Ability to multitask and work self-directed in a remote environment.
- Proficiency with MS Office Suite including Outlook and Teams.
- Ability to navigate ambiguity and changing healthcare environments.
- Knowledge of community resources.
Responsibilities
- Manage overall care management of nephrology patient caseload leveraging nursing and value-based care expertise.
- Facilitate seamless transitions for nephrology patients from Skilled Nursing Facilities to home or community.
- Collaborate with hospital discharge planners, providers, and SNF staff to address patient needs.
- Monitor patient progress and identify barriers to timely discharge.
- Participate actively in clinical huddles, interdisciplinary team meetings, and patient care conferences.
- Develop and implement strategies to optimize length of stay while maintaining high-quality care.
- Support transitions of care by addressing barriers and collaborating with care team stakeholders.
- Establish trusting relationships with patients and families to provide clinical and emotional support.
- Perform assessments identifying social determinants of health and develop patient-centric care plans.
- Foster communication and coordination with Skilled Nursing Facility stakeholders.
- Identify and implement evidence-based improvements in post-acute care processes.
- Engage in continuous process improvement to optimize workflows and patient engagement.
- Prepare and deliver reports on program success, patient outcomes, and satisfaction.
- Perform other duties as assigned consistent with the role.
Education
- Associate degree in nursing (ASN) required.
- Bachelor’s degree in nursing (BSN) preferred.
- Current Registered Nurse (RN) License required; Compact License preferred.
Benefits
- Competitive base pay with bonuses.
- Paid time off starting at 4 weeks for full-time employees.
- 12 paid holidays per year.
- Medical, dental, vision and life insurance including HSA with employer match.
- Reimbursement for continuing medical education.
- 401(k) with match.
- Paid parental leave.
- Robust training and development program.
Average salary estimate
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