Care Manager, RN

Current Saint Francis Employees
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Full Time Days Job

Summary:

Works collaboratively with physicians, staff and other health care professionals to provide patient centered medical home and care coordination across the health care continuum for all patients within the physician office setting. Is an integral member of the health care team who works to ensure safety, best practice and high quality standards of care are maintained across the continuum. Responsible for coordinating a wide range of self-management support and disease registry activities for the office’s patient population.

Success will be measured by the results of the process and outcome performance measure of the population of patients in the office. Works closely with the Warren Clinic Quality Improvement Council, Patient Centered Medical Home Committee and the Quality Team.

Minimum Education:

Has completed the basic professional curricula of a school of nursing as approved and verified by a state board of nursing, and holds or is entitled to hold a diploma or degree therefrom. Bachelor's or Master's of Science Degree in Nursing preferred.

Licensure, Registration and/or Certification:
Valid multi-state or State of Oklahoma Registered Nurse License and Basic Life Support (BLS) certification.

Work Experience:

3 - 4 years related experience with an understanding of systems and processes in outpatient medical group practices.

Knowledge, Skills and Abilities:

Demonstrates effective teaching techniques, applying adult learning principles. Demonstrates ability to coordinate appropriate educational materials for patients and their support systems. Demonstrates professional, appropriate, effective and tactful written, verbal and nonverbal communication with patient, families, medical staff, colleagues, vendors and other departments throughout the continuum of care to promote continuity of care and services and enhance Warren Clinic image.

Essential Functions and Responsibilities :
Oversees the disease registry database including: assuring database is kept up to date; identifying patients overdue for visits, labs or referrals and arranging for follow-up services as appropriate. Identifying patients not meeting clinical goals, such as blood pressure control or glucose control, and arranging for follow-up services by protocol or as appropriate. Creating patient, physician and office level quality performance reports.

Conducts and or facilitates pre-visit chart review of patients including: identification of all needed preventive health maintenance, immunizations and chronic disease interventions. When standing orders allow it the interventions may be ordered or completed before the patient sees the physician. Completes pre-visit forms or initiates office visit forms and communicates the review to the provider. Identifies most specific diagnoses codes to assist in achieving optimal Hierarchical Condition Categories (HCC).

Works with patients and families on self-management support including: setting short and long-term goals for self-management of chronic disease; addressing medication adherence in patients not meeting outcome goals. Works with patient to create a plan for health behavior change utilizing the 5A's approach (assess, advise, agree, assist, and arrange). Assessing and working on the patient's readiness to change, the importance of change and confidence in ability to change.

Helping the patient to identify and overcome barriers; makes a context specific clinically appropriate plan for follow-up between visits. Provides or arranges needed patient education regarding specific health care skills and general disease concepts. Assist with shared medical appointments; communicating face-to-face in the office setting, or by telephone, or by e-mail. Works independently to assess and evaluate understanding of disease process, treatment plan and / or lifestyle changes.

Coordination of care across the care continuum including: assists as liaison with patients and their families to physicians, clinical staff and other departments. Acting as a liaison with hospitalized patients and the clinic. Following up with patients by phone shortly after hospital discharge and at clinically appropriate intervals defined by protocol or physician discretion. Acting as a liaison with specialty providers;

proactively acts as patient advocate, responding to and working to resolve patient concerns. Providing a link to community resources. Involvement in quality…