RN- Patient Care Manager-Outpatient/Home visits in Indianapolis, IN at Eskenazi Health

Date Posted: 1/15/2020

Job Snapshot

Job Description

Organization: HHC

Division:Eskenazi Health  

Sub-Division: Hospital  

Req ID:  1871 

Schedule: Full Time 

Shift: Days 

Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 315-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus as well as at 10 Eskenazi Health Center sites located throughout Indianapolis.


The Intensive Care Manager, RN serves as a coordinator of care, collaborating in tandem with other members of the Care Integration Team, physicians, nursing, interdisciplinary team, and patients/families to provide seamless and efficient services for those within their assignment. This position functions as a Care Manager, providing assessments, demonstrating problem solving and critical thinking skills, and practicing effective decision making.


  • Proactively contributes to Eskenazi’s mission: Advocate, Care, Teach and Serve with special emphasis on the vulnerable population of Marion County; models Eskenazi values of Professionalism, Respect, Innovation, Development and Excellence
  • Serves as a coordinator of care, collaborating in tandem with other members of the Care Integration Team, physicians, nursing, interdisciplinary team, and patients/families to provide seamless and efficient services for those within their assignment
  • Clinically astute with their assigned patient population; responsible for managing each patient’s disease management education and maintenance, and their plan of care; ensures appropriate resource utilization; coordinates the patient’s care across the continuum
  • Serves as a patient advocate, pursuing the common goal of delivering quality and efficient health care
  • Provides face to face, home, or telephone visits to address patient’s needs
  • Triages incoming calls from patients and performs follow up calls to assigned patient population
  • Assesses needs, clinical options and facilitates referrals to appropriate providers and community resources
  • Coaches and  monitors disease control and psycho-social indicators; works with the patient’s primary care team to make changes in medications and lifestyle when treatment goals are not being reached
  • In tandem with patient/family, sets realistic step-by-step goals to reduce specific chronic disease and psycho-social indicators
  • Serves as an integral part of the care team to mitigate long-term medical and financial risks from poorly controlled chronic diseases
  • Independently functions as a Care Manager, providing assessments, demonstrating problem solving and critical thinking skills, and practicing effective decision making
  • Initiates appropriate actions in situations that place patients at risk
  • Demonstrates knowledge of pathophysiology, pharmacology and disease processes for the assigned population, and age-appropriate care

The following items detail the above and are organized in four main disciplines that define the Transition of Care-Care Manager role:  Case Management, Financial Assessment, Social Assessment/Transition Planning and Community Outreach/Engagement

Case Management:

  • Collaborates and maintains active communication with physicians, interdisciplinary team, nursing and patients/families to ensure timely patient progression through the episode or plan of care
  • Addresses and resolves problems impeding diagnostic or treatment progress
  • Proactively identifies and resolves delays to transitioning
  • Utilizes conflict resolution, critical thinking, and negotiation skills as necessary to ensure timely resolution of issues
  • Identifies and plans strategies to ensure proper utilization of resources within the targeted population
  • Interviews patients and other relevant sources; collects and assesses specific information in an attempt to identify individual needs and develop a comprehensive plan of care that addresses medical, social and financial needs
  • Collaborates with the Director of Ambulatory Integrated Care and Director of Inpatient Integrated Care, as well as the Physician Advisor to identify cases that require special intervention
  • Actively participates in creating/planning an action-oriented and time specific plan of care
  • Maintains and ensures adherence to clinical pathways/protocols and the appropriate use of clinical tools through collaboration with physicians, interdisciplinary team, nursing, CORE, community health workers, Integrated Care Coordinators and Transition of Care staff
  • Continually reassesses and monitors patients for change in condition warranting initiation of a clinical pathway, alteration in plan of care, or change in care acuity in an attempt to determine the effectiveness of the care plan
  • Evaluates at appropriate intervals that the quality of health care to each patient is delivered in an efficient manner throughout the continuum of care
  • Measures the Care Integration interventions to determine goals and outcomes
  • Focuses on patient advocacy

Financial Assessment:

  • Educates physicians, interdisciplinary team, and nursing, regarding payer sources and the role this plays in transition planning
  • Collaborates and communicates as necessary with the managed care case managers, integrated care coordinators, Transition of Care staff, CORE staff, and community health workers
  • Collaborates and communicates as necessary with the on-site private payer/managed care case managers
  • Evaluates the active funding for each patient and communicates with Financial Counseling to facilitate the initiation of appropriate funding applications as necessary.
  • Addresses financial barriers to healthcare/medical compliance with the patients and families when indicated

Social Assessment/Transition Planning:

  • Interviews patients and other relevant sources; collects and assesses specific information in an attempt to identify individual needs, and develops a comprehensive plan of care which identifies these needs; develops an appropriate, safe, and personalized plan of care
  • Monitors the plan of care for assigned patients and collaborates closely with other members of the Care Integration team for planning
  • Facilitates transition services such as Home Health Care, Substance Abuse Treatments and durable medical equipment
  • Documents relevant processes and care plan information in medical record appropriately

Community Outreach & Patient Engagement:

  • Develops and fosters clinical, community, and home based relationships to enhance chronic disease management, transitions in care and the overall improvement of behavior and health outcomes
  • Provides education to patients and their families that are adapted to their unique needs, lifestyle, cultural and socio-economic situations
  • Educates and informs patients of community resources that are located within their neighborhood community
  • Advocates on behalf of vulnerable patients and participates in assessing and evaluating their need for health care services and community programs; assists them with getting connected to those services
  • Attends relevant community meetings to stay informed of resources that may benefit the patient
  • Maintains relationships with collaborative partners and cultivates new ones


  • Participates in continuing education exercises when available and shares that learning with the team
  • Demonstrates a positive attitude and ensures compliance with professional standards and requirements
  • Actively participates in department activities such as staff meetings, in-services, case conferences and statistical analysis of outcomes
  • Participates in and ensures all components of safety, ethical and legal compliance
  • Participates in clinical performance improvement activities as appropriate and shares information with the Interdisciplinary team
  • Performs other job-related duties as assigned


  • Current Indiana licensure as a Registered Nurse required
  • Three years of clinical nursing experience required



  • Demonstrates knowledge of the case management, patient education and care coordination process
  • Demonstrates effective communication skills, knowledge of disease processes, and normal growth and development for all age groups, in order to ascertain an accurate understanding of the patient’s symptomology
  • Competency in the following areas required:
    • interpersonal, written/verbal communication and negotiation skills
    • diplomacy, flexibility and professionalism
    • cohesive networking with the interdisciplinary team


  • Maintains patient and family confidentiality
  • Maintains confidentiality of information by assessing proper handling and distribution of records/diagnosis, and by differentiating appropriate authorities for whom information can be legally released
  • Maintains protected health information in accordance with HIPAA privacy guidelines and regulations


  • Employee may work independently under the general direction of their leader


  • Continuous contact with primary care providers, Transition of Care staff, CORE staff, interdisciplinary team, nursing staff, Social Workers, patients and families
  • Ongoing contact with representatives from outside referral agencies


  • Works independently with general guidelines/procedures that define work activity
  • Uses sound judgment when making decisions of a non-routine nature on a regular basis
  • Demonstrates patience, professionalism and sensitivity to work in a crisis-oriented field with a variety of non-health care professionals
  • Intermittent exposure to patient care areas


  • Office area – works primarily in Eskenazi Health Center with routine presence in the hospital campus/units, educational settings, community agencies, Health Information Management and other patient service departments.
  • May be required to attend meetings or perform work remote from clinic or hospital campus
  • May be required to conduct  home visits in the patient’s home
  • Duties performed in clinics/office/hospital units, educational settings and community agencies
  • Extensive telephone usage

Accredited by The Joint Commission and named one of the nation’s 150 best places to work by Becker’s Hospital Review for four consecutive years and Forbes list of best places to work for women, and Forbes list of America’s best midsize employers’ Eskenazi Health’s programs have received national recognition while also offering new health care opportunities to the local community. As the sponsoring hospital for Indianapolis Emergency Medical Services, the city’s primary EMS provider, Eskenazi Health is also home to the first adult Level I trauma center in Indiana, the only verified adult burn center in Indiana, the first community mental health center in Indiana and the Eskenazi Health Center Primary Care – Center of Excellence in Women’s Health, just to name a few.


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