RN Case Manager - Care Ally - Cardiology

Overview

RN Case Manager - Care Ally - Cardiology
-Hybrid Opportunity

• Full-Time, 40 hours per week. Monday through Friday, 8:00 a.m. to 5:00 p.m.; flexibility to work later as needed

• Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
• Access to a mental health benefit at no cost.
• Employer provided life and disability insurance.
• $5,250 Tuition Reimbursement per year.
• Immediate 401(k) match.
• 40 hours paid volunteer time off.
• A culture committed to community engagement and social impact.
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.

The Cardiology RN Care Manager is a critical member of our integrated specialty care team consisting of nurses, dietitians, pharmacists, care coordinators, and physicians. The Cardiology RN Care Manager will be working in collaboration with the specialty care team, healthcare professionals, patients, and families to provide ongoing support and communication to a high-acuity population of patients with complex cardiac conditions, including congestive heart failure (CHF) and other comorbidities.

The primary focus of the role will be to improve patient outcomes, including delaying disease progression, avoiding unnecessary inpatient and emergency department utilization, educating patients on self-management, and ultimately better long-term cardiac outcomes. The role is integral to our specialty care team and will focus on advanced clinical support through clinical triage, care plan development, and high-risk care management. In addition, the Cardiology RN Care Manager will assess and coordinate resources available to patients and maximize the use of health care benefits.

The Cardiology RN Care Manager will be supported by predictive data to identify patients with complex cardiac conditions and high-touch care workflows that integrates with Duly’s primary and specialty care providers. While primarily conducted via telecommunication, this role may necessitate on-site visits to various healthcare clinics. This position will also serve as the clinical escalation point for non-RN Care Coordinators, supporting continuity and collaboration across the care team.

• Enroll and manage a case load of patients with complex cardiac conditions, including CHF
• Conduct comprehensive clinical assessments via phone, including medical, behavioral, pharmaceutical, and social needs of the patients per policies and procedures.
• Maintain proactive communication with Cardiologists, APPs, PCP offices and other clinical partners to ensure timely clinical escalation, alignment with treatment plans, and coordination of services
• Coordinate with transition of care team (TCM) to support post-discharge care, including medication reconciliation and timely follow-up with Cardiology
• Inventory and reconcile medications and coordinate with pharmacists and prescribers; encourage medication and treatment adherence through frequent contact with patients
• Assess home safety and social determinants of health (SDOH) barriers, including transportation, food insecurity, housing instability, and caregiver support; escalations of resources where appropriate.
• Perform patient health assessments and surveys as required
• Facilitate care across the continuum of care, spanning settings such as the home, hospital, and skilled nursing facilities
• Manage patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions
• Provide patient and caregiver education; assess the patient’s knowledge of their cardiac condition and provide education and self-management support
• Serve as the initial point of contact for escalations and provide clinical oversight to Care Coordinators, including delegation of tasks as appropriate
  
  Review and document patient updates and progress
• Educate patients and facilitate conversations around proactive care decisions, especially relating to Advance Care Plans
• Analyze data collected from the predictive modeling tools to identify eligible patients for care management
• Proficient in knowledge of current…