Covenant Health

Registered Nurse Care Manager, Continuum of Care 

Full Time, 80 Hours Per Pay Period, Day Shift

Days, Monday-Friday, 8am-4:30pm, occasional weekends, rotate minor holidays

Parkwest Overview:

Headquartered in Knoxville, Covenant Health is a community-owned integrated healthcare delivery system and the area’s largest employer.

Parkwest is Covenant Health’s and West Knoxville’s premier medical facility and a top-performing heart hospital, offering our patients world-class treatment with all the convenience and warmth of home.

In addition to providing the area’s leading cardiac services, Parkwest has been nationally recognized for award-winning care throughout our facility. For 2020-21, Parkwest received recognition from U.S. News & World Report as one of the “Top 10” hospitals in Tennessee.

Knoxville located in East Tennessee is the third largest in the state, well-known for its proximity to the Great Smoky Mountains National Park, and is the home of the University of Tennessee. Go Vols!  Living in Knoxville means experiencing all four seasons.  Best of all, each of them is pretty mild!

Combine all that with the abundant natural beauty of the surrounding mountains, and you have a city that truly offers something for everyone. Knoxville has a vibrant arts culture, seasonal festivals, top-notch foodie and incredible outdoor recreation. It’s a perfect blend of big-city amenities and Southern charm.

Continuum of Care:

The Continuum of Care Department is staffed by a Manager, Coordinator, RN Care Managers, and Masters Level Social Workers. They are involved in the assessment, planning, coordination, evaluation, and facilitation of services to meet the patient’s and family’s comprehensive health needs. Effective and open communication are necessary to promote quality and cost effective outcomes. A multidisciplinary, collaborative, team approach is essential in working to meet the patient/care giver transition of care needs and facilitating a safe discharge. Staff must be patient advocates and aware of community resources. Seasoned and newer employees work together in a challenging, ever changing environment.  The department is staffed 7 days a week. The department works all minor holidays. Scheduling is centered on team and department needs.

Case Managers and Social Workers are available for all patient care areas including the Childbirth Center, SBU, ED, and outpatient areas.The department hires RNs with a minimum of 3 years of experience. Case Management certification is preferred, but not required. There is a career ladder for eligible RNs. New grads and experienced persons are considered for the Masters level Social Worker position.

Position Summary: 

The RN Care Manager I is responsible for integrating evidenced based clinical practice into the patient care setting, coordinating education of staff and patients and serving as a clinical resource and consultant to the health care team.  The RN Care Manager I is responsible for promoting patient care continuity and quality through the collaborative development of practice guidelines and clinical pathways that support quality improvement activities.  The RN Care Manager I actively seeks opportunities in research designed to identify best practices.  The RN Care Manager I has the responsibility, accountability and authority for providing comprehensive care coordination and knowledge to plan, implement, monitor and evaluate the outcomes of care for the designated patient population. The RN Care Manager I is seen as part of the management team on the nursing unit and reports directly to the Manager of Quality and Care Management at the facility level.

Recruiter: Angelica Adams || aadams16@covhlth.com || 865-374-5405

Assessment:

• The RN care manager utilizes case finding criteria to screen patients and gather information from the medical record, physician documentation and communication, patient/family as well as other sources to develop a comprehensive plan for the patient that will meet identified needs.
• The RN care manager utilizes the nursing process to evaluate daily through discussion with patient and care givers and chart findings to ensure patient is meeting daily objectives
• The care manager modifies the case management plan to meet the changing needs of the patient’s clinical condition. Secures needed resources via a multidisciplinary approach to care management strategy to assure timely, efficient and cost effective services.

Collaboration and Planning:

• Designs and implements practice guidelines and clinical care designs in collaboration with physicians, nursing and other members of the health care team for assigned population.
• Identifies specific objectives, goals, and actions to meet the patient’s identified needs.
• Collaborates and communicates effectively with the physician and other members of the health care team to plan and implement the care of the patient in a timely manner. Documents results of communication in the patient’s medical record.
• Participates in daily multidisciplinary rounds and ensures appropriate disciplines are available

Communication, Implementation, and Coordination of Care:

• Works closely with the physician to identify the necessary resources and ensures the appropriate utilization of same.
• Communicates effectively with physician offices, home health agencies, rehabilitation facilities, long term care facilities, and third party payers to identify goals to assure that patients receive the most appropriate, cost effective and efficient means of care. The RN Care Manager provides documentation in the patient’s medical record to communicate the goals and transition plan for the patient.
• Executes and documents the Care Management activities and interventions related to specific patient goals.
• Serves as liaison to provide communication with the patient/family, physician and the health care team.
• Coordinates, organizes, secures, integrates, modifies and documents resources needed to accomplish goals related to the Care Management discharge plan.
• When necessary, serves as the “brokering” agent to secure coverage for needed community services.

Monitoring:

• Gathers sufficient information from all relevant sources and documentation regarding the care management plan and activities and or services to enable the Care Manager to determine the plan’s effectiveness.
• Mobilizes resources and coordinates the effort of the health care team to achieve a positive patient transition to appropriate next level of care.
• Identifies, communicates and initiates actions to mitigate variances in the patient’s process of care.
• Stays abreast of most recent changes in quality related to core measures, Conditions of Participation, Leapfrog and other regulatory bodies to assist in compliance for assigned population
• Monitors patient population for potential Healthcare Acquired Conditions, Hospital Acquired Infections and proactively initiates actions to prevent same

Discharge/Transition Planning:

• When necessary, serves as the “brokering” agent to secure coverage for needed community services.
• Mobilizes resources and coordinates the effort of the health care team to achieve a positive patient transition to next appropriate level of care.
• Ensures Multidisciplinary daily rounds at the patient’s bedside with care giver and health care team to successfully achieve the desired outcomes and goals.
• Evaluates the Care Management plan and modifies or changes the plan as needed to meet the patient’s needs.

Outcomes/Clinical/Fiscal/Resource Management:

• Utilizes statistical analysis techniques to measure clinical and fiscal variances from established patient care guidelines, care designs, protocols and core measures.
• Develop reporting mechanisms to communicate outcomes to physicians and other members of the health care team.
• Supports cost containment efforts through the recommendation of performance improvement opportunities by the health care team.
• Maintains ongoing fiscal awareness by communicating outcomes to all stakeholders at specified times
• Monitors and addresses outcome variances concurrently.
• Identifies causes of outcome variances and implements actions to improve the variances; evaluates corrective actions for improvement.
• Proactively seeks the most efficient, cost-effective ways to provide appropriate care.
• Conducts research to identify “best” practices for achieving patient outcomes.
• Participates in quality improvement initiatives for assigned population.
• Addresses end of life issues as they arise with the physician, family and other members of the health care team.
• Maintains patient Privacy information with other facilities, services and departments involved in Interdisciplinary Discharge Planning Rounds.

General Duties:

• Follows policies, procedures, and safety standards. Completes required education assignments annually. Works toward achieving goals and objectives, and participates in quality improvement initiatives as requested.
• Provides care management services within the scope of practice as a registered nurse meeting all required standards both legal and regulatory.

Education:

• In collaboration with Nursing and other members of the health care team, plans, develops and assists in patient education; requires return demonstration to ensure patient and family understanding of inpatient plan of care as well as post discharge needs
• Participates in staff development, orientation, and unit meetings through mentoring, consultation, educational presentations and clinical direction.

Leadership:

• Assists with the hiring, supervision, education, orientation, evaluation and disciplining of staff.
• Maintains awareness of all hospital policies applicable to the care of the assigned patient population.

Minimum Education:   

None specified; however, must be sufficient to meet the standards for achievement of the below indicated license and/or certification as required by the issuing authority. 

Minimum Experience:   

Three (3) years of nursing experience; a minimum of two (2) years of experience in areas of assigned responsibility.

Licensure Requirement: 

Current Tennessee RN License. 

RN License