Job Description:

Scope

Nurse Care Manager-MG works in the ambulatory setting. The position may work in a general care manager model to support three or more clinics within a scope narrowly aligned with designated Primary Care Clinical Program initiatives or may work in a Personalized Primary Care model (1-2 clinics) with broad scope for a defined patient population. Patient interactions may be in person, by telephone, or other electronic means.

Job Essentials

General case management
Responds to physician referrals and identifies patients who meet established criteria for care management (e.g. HgA1c > 8, elevated LDL and/or B/P, Mental Health Integration referral, complex resource needs).

Patient Evaluation
Assesses family, social, cultural characteristics.
Understands communication needs (e.g., vision, hearing).
Assesses behavioral and family risk factors.
Assesses barriers.
Screens for chronic disease (e.g. depression).
Reviews patient understanding of medication treatment.

Chronic Disease Management
Utilizes a working knowledge of established care process models and other applicable standards of care.
Provides focused patient education using established content and tools.
Uses clinician approved and appropriately documented standing orders.
Establishes individualized care plan including treatment goals in collaboration with patient and consistent with medical plan of care.
Reviews care plan and assesses progress toward treatment goals and barrier at each relevant visit.

Coordination of Care
Coordinates with care managers in other settings as appropriate.
Provides information on enabling services (e.g., transportation).
Maintains list of key community services agencies with contact information.
Provides information about recommended or available services and contacts.
Personalized Primary Care.

Support Patient in Self-Management and Behavior Change Using Motivational Interviewing and Coaching
Assesses readiness to change.
Assesses and tracks patient capacity for and confidence in self-care.
Develops self-care plan in collaboration with patient.
Provides self-monitoring tools.
Provides or connects patients with support programs.
Assesses and supports patients in adopting healthy behaviors.
Assesses and arranges treatment for mental health and substance abuse problems.

Manage Populations, Disease Registries and Preventive Care
Establishes process to monitor patient adherence to medical plan of care.
Focuses on prevention measures consistent with established guidelines and care process models
Reviews and manages quality reports related to chronic disease and prevention
Supports clinicians in achieving quality incentives.

Team Based Care
Works collaboratively with referring physician and other members of care team
Personalized Primary Care:
Completes pre-visit planning (review chart before visit, notify patient of tests needed before the visit)
Facilitates advanced care planning (Advanced Directives). Establishes a process for reminder letters and phone calls.
Supports clinicians and team to achieve personalized primary care goals.
Facilitates transitions of care (e.g., unscheduled hospital admissions, emergency department visits, skilled nursing home).
Tracks status of critical referrals.
Follows up to obtain report back from referral clinician.
In collaboration with clinician, establishes written care plan for patients transitioning from pediatrics to adult.
Provides information on health insurance resources.
Supervises and supports Health Advocates.
Attends clinic team meetings and medical home meetings to assist with process design and help resolve team issues.
Supports development of agenda for team meetings.
Reviews data summary on regular basis.

Minimum Qualifications

• Current RN license for state in which the nurse practices.
• BLS certification for healthcare providers.
• RNs hired or promoted into this role need to have or obtain their BSN within three years of hire or promotion.
• Three years of clinical nursing experience.

Preferred Qualifications

• Bachelor's degree in Nursing (BSN). Education must be obtained from an accredited institution. Degree will be verified.
• Experience in case management, utilization review, or discharge planning.
• Cardiac Background

Ongoing need for employee to see and read information, labels, monitors, identify equipment and supplies, and be able to assess patient needs.
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Frequent interactions with patient care providers, patients, and visitors that require employee to verbally communicate as well as hear and understand spoken information, alarms, needs, and issues quickly and accurately, particularly during emergency situations.
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Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy. This includes frequent computer use and typing for documenting patient care, accessing needed information, etc.

Location:

Work City:

Work State:

Scheduled Weekly Hours:

The hourly range for this position is listed below. Actual hourly rate dependent upon experience.

We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.

Learn more about our comprehensive benefits package .