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About the Role

At Hopscotch Primary Care, we take a team approach to serve patient needs and provide the best care possible. Our goal is to provide the care each of us would want for ourselves or for our family members, in the right setting and at the right time. The Hopscotch Care Team is responsible for delivering high-touch, high-quality care to patients, including coordination of care across different physicians and within the healthcare system.

As a Care Manager Registered Nurse, you will play an important role in the care for our patients by achieving positive patient outcomes and by managing quality of care across the continuum of care. This professional will partner across the care team to develop effective plans of care and achieve high levels of communication and coordination for care planning and care delivery. Establishing strong and trusted relationships across the care team and with patients, their families and caregivers, other providers outside Hopscotch and those within the community will be critical to enabling success.

This role is based in Hudson, NC and will start in September 2024.

What You'll Do

Specific responsibilities for this role include but are not limited to:

• Manage end-to-end case management services to a defined panel of risk-stratified patients:
  • Relationship Development and Navigation of Healthcare Ecosystem:
    • Establish and maintain trust and strong relationships across care team, patient/family/caregiver and broader provider and community ecosystem to enable full spectrum care management
    • Build relationships across provider community and leverages data/team insights to refer care to preferred providers
    • Manage and plan for transitions of care, discharge and post discharge follow-up for patients transitioning to/from a hospital, ED, or SNF
      
  • Care Coordination, Planning and Collaboration
    • Collaborate with clinical staff in the development and execution of the plan of care and achievement of goals. Report variations to the care team and take actions as appropriate.
    • Coordinate the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting. Coordinate the patient care, discharge and home planning processes with hospital case management departments, and other healthcare facilities
    • Communicate proactively with patient/family, care team and provider partners around needs, updates and actions required to enable patient care and outcomes
    • Address advanced care planning including treatment goals and advanced directives
      
  • Patient Support and Advocacy
    • Actively advocate for the patient and serve as a resource for the family to maximize their ability to make informed, timely decisions and to enable patient outcomes
    • Provide family education, identify post-hospital needs and coordinate planning to ensure needs are met

• Support best practices and protocols for care management and demonstrate commitment to clinical excellence, quality and compliance:
  
  • Direct and participate in the development and implementation of patient care policies and protocols to provide advice and guidance in handling unusual cases or patient needs
  • Support training and education around care management and related topics, including the development of new resources to support best practices and processes
    
  • Investigate and report adverse occurrences, and perform staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery
  • Adhere to Hopscotch Code of Conduct and proactively live the Hopscotch values

About You

You would be a great fit for this position if you have:

• An associate’s degree in Nursing (required)
• A Bachelor of Science Degree in Nursing (BSN) or an RN with a bachelor’s degree in a related clinical field (preferred)
• A minimum of 2 years of clinical work experience
• A valid, active Registered Nurse (RN) license in State of employment
• A minimum of 1 year of utilization review or case management (required)
• Certification in Case Management (preferred)
• Experience utilizing electronic medical record systems and proficiency with technology
• Knowledge of the healthcare system, including community health services, social support services and providers (specialists and hospital systems)
• Knowledge of regulatory requirements, including Medicare, Medicaid, FDA, DOT, OSHA, state requirements, health care accreditation, and professional standards of practice (preferred)
• Ability to travel locally and regionally, as needed
• US work authorization

Additional skills and capabilities required:

• Strong interpersonal and communication skills, verbal and written
• High emotional intelligence and strong collaboration skills working with diverse groups
• Skill with motivational interviewing, behavior change, health promotion, and coaching
• High attention to detail, organization, coordination and planning skills
• Solid problem solving and critical thinking skills
• A proven ability to learn complex topics quickly and put knowledge into action

From a cultural perspective, you:

• Create a culture of excellence, by bringing your best and encouraging the same from those around you
• Put service to patients first and encourage the same of those around you
• Take ownership and accountability for your work and for delivering results for patients
• Assume the best in others and bring solutions to challenges with a focus on moving forward together
• Show an active commitment to the team by collaborating and communicating proactively
• Demonstrate a dedication to continuous improvement, in clinical and cultural settings