Inpatient Discharge Care Manager

Community Health Network of Connecticut, Inc. (CHNCT) is currently seeking an Inpatient Discharge Care Manager in the Greater New Haven, CT area. Primary Responsibilities: Collaborate with hospital, PCP, home health agency, member, and CHNCT Intensive Care Managers (ICM) to identify and address clinical and social determinants that contribute to readmissions to develop a comprehensive discharge plan. Meet with members who are inpatient to assess barriers to safe discharge including physical needs, cognitive deficits, psychosocial needs, and/or lack of a primary care physician or other outpatient support systems in place. Provide health education and information on available HUSKY Health and community resources to members. Communicate gaps in care and barriers to safe discharge with hospital care coordinator, attending physician, ICM and Primary Care Provider (PCP). Partner with team to develop outpatient strategy to include proper follow up with physicians/specialty providers, obtain care in the appropriate setting, and address social determinants. Tasks Performed: Complete face to face visits with members while in the hospital. Conduct comprehensive assessment of 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, ICM and outpatient providers within two days of admission. Participate in internal and external collaborative meetings. Initiate referrals as necessary. Identifies and refers Quality of Care (QOC) issues to the Quality Management department. Perform other duties as assigned. Essential Functions: Develops and maintains collaborative relationships with internal constituents and 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 (i.e., multiple co-morbid conditions, pain management, behavioral health issues, alcohol/substance abuse, and chronic pain) 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 Desired Degree: Associate's degree, Bachelor's degree preferred Desired Major: Nursing Desired Job Experience: 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. 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.