RN Disease Manager

Job Description

Health Partners is hiring an RN, Disease Manager. This position is focused on providing telephone-based services, including outreach, evaluation, engagement, education, counseling, self‑management support, and care integration for individuals in chronic disease management programs. Implements performance improvement strategies as identified through review of patient and program outcomes. Demonstrates dependability for patients and disease management team. Facilitates communication between patient, health care provider, and community.

Integrates and coordinates the expertise and support of other health professionals, family members, and health care providers across the care continuum.

• Ensures all activities are patient‑focused and individualized, resulting in personalized attention to each individual’s unique needs.
• Identifies interventions and resources to assist patient in reaching personal health‑related goals.
• Identifies patterns and improvement strategies to help patients improve their health and achieve optimal care goals.

• Refers to and co‑manages with Complex Case Management and Inpatient Case Managers when patient’s condition requires higher level of management.
• Interacts with referral sources from other health care providers, engages patients referred to the disease management program, and refers patients back to their care provider or other resources as appropriate.
• Integrates patient’s individual clinical, functional, and health behavior information to develop action‑oriented and time‑specific planning and implementation of appropriate interventions.
• Facilitates integration of patient care by encouragement of effective communications between patients, families, providers, and care system programs, and community‑based services.
• Adheres to department policy and procedures in all daily activities.

• Effectively and routinely communicates with patients and their families to provide them with a better understanding of their health and to facilitate successful health outcomes.
• Communicates and collaborates with primary care and specialty providers in support of optimal patient health outcomes.
• Provides education and self‑management support as it relates to managing chronic illness.
• Facilitates successful collaboration resulting in high patient, provider and employee satisfaction levels.
• Maintains current and accurate documentation of disease management activities and assists in tracking database outcomes.
• Maintains confidentiality of information in accordance with department and corporate policies.

• Establishes and maintains good working relationships with the Disease and Case Management department, with other Health Partners departments, and with other health care team participants to co‑manage services and care for patients in chronic disease management programs, including those in clinical care delivery settings.
• Participates in and contributes to appropriate departmental and/or organizational meetings.
• Works cooperatively with leadership in support of the business goals and objectives of the department.

• Maintains knowledge of and effectively uses automated applications and systems.
• Maintains the ability to utilize guidelines and standards of care for management of chronic diseases.
• Identifies deficits in technological literacy and seeks appropriate training under guidance of supervisor.
• Maintains maximum individual productivity through proficient use of automated systems.

• Proactively participates in ongoing education‑related professional activities to maintain and increase knowledge in the areas of health behavior change and chronic disease management.
• Maintains current licensure and certifications as applicable.
• Demonstrates responsiveness to, and appreciation of constructive feedback and recommendations for personal growth and development.

• Willingly participates in various committees, task forces, projects, and quality improvement teams, as needed and assigned.
• Performs other duties as assigned.

• Registered Nurse with current unrestricted…