Clinical Care Manager

Overview

Primary Function. The incumbent performs nursing procedures to patients of all ages independently within the framework of established policy. The Registered Nurse is a licensed professional nurse responsible for assessment of patients, development, implementation and evaluation of a patient plan of care; administration of therapeutic measures; teaching and counseling of patients and families; and participating in the development of nursing policies and procedures and quality assurance standards.

The Registered Nurse is responsible for the delivery of comprehensive health care to patients of all ages, utilizing standards of care and practice, policies, protocols, and procedures. The purpose of the work is to perform the full range of the nursing process from assessment to evaluation. The work affects the physical and psychosocial well being of the patients and their families.

• Utilizes best practice models to identify, incorporate or develop best practices for panel management. Collaborates with other teams to share and establish best practice for health promotion and disease prevention strategies.
• Manages panel by addressing and resolving acute care needs and chronic care needs through a team-based approach.
• Incumbent will be responsible for leading their pod and assisting the Primary Care Provider in panel management that results in meeting facility, national, and regulatory quality indicators.
• Utilizes iCare to track, monitor, and assure the appropriate follow-up of clients targeting specific indicators.
• Utilizes the care management platform for documentation of care management functions such as a care needs screening, Comprehensive assessment, and care planning. Also utilizes the dashboards, within the care management platform for population health and related interventions and innovations
• Utilizes NC Health connects for information gathering and data collections for management of care needs or gaps in care
• Coordinates and follows up on referrals to outside specialty providers, recent ED visits, and ICC visits. Emphasis is placed on ensuring treatment notes are available to the PCP timely.
• Participates in the continued development of the role of Case Management in the Patient Centered Medical Home (PCMH) and Advanced Medical Home (AMH and AMH+).
• Provides standard nursing care for patients throughout the age continuum.
• Develops implements and evaluates care plans.
• Promotes health care outcomes with currently accepted clinical practice guidelines.
• Provides patient education, advice and information on health assessment, disease processes, medications, treatment plans and available community resources.
• Assesses patient needs using established clinical guidelines, protocols, and pathways.
• Provides appropriate follow up as directed or per established guidelines.
• Provides nursing care in accordance with established nursing care standards, participates in routine and specialty clinics, curative, rehabilitative, and preventive nursing care. On rare occasions may be required to participate in emergency care.
• The incumbent will be evaluated annually on his/her ability to identify, assess, analyze, and evaluate data and solve problems through the CIH Performance Appraisal System.
• Performs ongoing assessment by actively participating in the determination of meeting the nursing care needs based upon collection and interpretation of data relevant to the health status of the client.
• Collects data from relevant sources (patient, family, or caregiver) regarding the biological, psychological, social and cultural factors that might influence and impact the health status of the individual and utilizes this data in patient center care plan development.
• Collects data through observations of appearance and behavior, measurements of physical structure and physiological function, and other information in an effort to place consultations and/or referrals to the correct internal and external resources (Nutrition, Tsali Manor, etc).
• Interprets data and recognizes existing relationships between data collected and the client’s health status and treatment regimen and determines the client’s need for immediate nursing interventions.
• Reviews the patient’s health records and health summary, interviewing patients and family members, documenting the chief complaints, medical history, physical and clinical findings, identifying learning needs of the patient and family, and determining priority of care required. Assessment for health prevention, health promotion, restorative, and health maintenance needs is emphasized.
• The nurse will plan patient care according to individual assessed patient needs and established hospital policies and procedures.
• Functions as charge nurse when assigned by the Outpatient Administrator; assigns nursing staff according to staff competency and patient complexity and provides technical supervision for staff members, including reviewing procedures; anticipates problems and acts to resolve problems.
• Develops…