Mercy Health System of Maine

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Care Manager RN -Post Acute - CARE COORDINATION - 45641

at Mercy Health System of Maine

Posted: 9/27/2019
Job Reference #: 1027978
Keywords: healthcare, patient

Job Description


Beacon Health


Regular Full-time




Maine RN License or eligible to obtain


Oversee clinical care to patients requiring care in post–acute care settings. Serves in an expanded nursing role to collaborate with the Medical Team to provide a model of care that ensures the delivery of quality, efficient, and cost effective healthcare services. Promotes integration of evidence based clinical guidelines, preventive guidelines, protocols, and data analytic metrics into the development of treatment plans that are patient-centric. Promotes the appropriate level of care across the care continuum. Reports to: Regional Manager, Care Coordination for Beacon Health, LLC.


· Manage utilization and clinical metrics to refine the delivery of care model to maximize clinical, quality and fiscal outcomes for the population.

  • Monitor patient progress and promote early intervention in evolving acute care situations.
  • Responsible for implementing and oversight of SNF Waiver program (when available) to qualified patients. including on-call coverage responsibilities as needed.
  • Provide education to individuals, groups, practices and organizations regarding the SNF Waiver program opportunity.
  • Provide safe transition of care across the continuum of care.
  • Provide patient-centric education.
  • Promote patient independence and self-management.
  • Responsible for the assessment, planning and implementation process for a select group of patients in the post-acute setting.
  • Demonstrate autonomy and accountability.
  • Actively negotiate and influence individual and group decision- making.
  • Adapt to a fluid, dynamic and rapidly changing environment. Demonstrate leadership qualities in the areas of time management, problem solving, decision making,priority setting, delegation, organization, written/verbal communication andlistening skills.
  • Implement monitoring systems for patients requiring post-acute care settings; including the transition to and from, and during their care in the post-acute care setting.
  • Continuously evaluate laboratory results, diagnostic tests, utilization patterns and other metrics to monitor quality and efficiency results for population.
  • Provides regular progress updates to PCP and other members of the care team.
  • Collaborates with the care management teams across the care continuum to ensure smooth process in place when movement between settings occurs.
  • Collaborates with post-acute providers and facilities to maximize clinical, quality and fiscal outcomes for the population.
  • Interface with payers and participate in payer learning activities.
  • Provides onsite visits to SNFs and Home Health Agencies to serve as a liaison for post-acute patients.
  • Advocate for patients benefits as they qualify for skilled rehabilitation and homehealth services.
  • Other duties as assigned.


Needst o be professional as well as knowledgeable, responsible, and accountable to manage patient care over the continuum and to assist in, improving quality,cost, and patient/service experience outcomes. Organized, self-motivated and prioritize competing duties to complete projects within designated timelines.

Proficient in computer literacy including but not limited to the electronic medical record, electronic data entry, retrieval and report generation.

Demonstrates proficiency in basic computer skills, including accurate keyboard entry of data into relevant computer based databases and spreadsheets.

Demonstrates proficiency with Microsoft Word and Windows & Excel, and the ability to learn various system software. Demonstrates ability to use basic office equipment, computer, fax machine, copier,calculator, etc.

Work effectively with clinical and non-clinical staff.

Excellent communication skills.

Perform multiple tasks simultaneously.

Motivate others.

Work with people from diverse backgrounds and experiences.

Ability to openly address and acknowledge observed issues and concerns.

Pass background check.

Detail oriented.


Registered Nurse with three to five years of recent (within the last 3 years) acute care experience or relevant experience required.

Licensed at an RN level (or eligible to obtain) by the State of Maine Board of Nursing.

Bachelor's degree in Nursing preferred

Knowledge of skilled levels of care and care coordination required.

BLS Certification.

Experience with care management/care coordination to include care planning, resource management, and utilization management desired. Prior experience in Post-acute setting desired.

The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.