Nurse Care Manager

Job Summary

The Nurse Care Manager provides professional, patient-centered nursing care in the ambulatory setting in accordance with the multi-disciplinary plan of care and established policies, under the supervision of the Lead Nurse. The role includes direct nursing and telephonic services to patients and families, collection and analysis of patient data, development and maintenance of care plans, evaluation of outcomes, documentation, and communication of interventions.

Tasks are delegated appropriately and compliance with regulatory standards such as the Joint Commission and PCMH is ensured.

• Utilizes assessment skills to evaluate patient needs and formulate a plan of care as part of the multi-disciplinary team, revising outcomes and interventions based on ongoing evaluation.
• Facilitates individual or group nursing visits to address chronic illnesses and provides education on disease management.
• Identifies patients at risk for poor outcomes and provides additional outreach and frequent follow-up by phone and in-person.
• Provides complex case management, including chronic disease, critical diagnosis care coordination, transition care management, high-risk clinical tracking, complex medication management, and system utilization.
• Offers medication reconciliation and adherence counseling while assessing patient knowledge and barriers to self-care.
• Triages patients during walk-in or same-day clinic.

• Collaborates with the multi-disciplinary team to address physical and psychological health aspects for comprehensive care.
• Works with the Transition of Care Team to ensure safe and effective transitions.
• Collaborates with providers during appointments or nursing visits for health promotion, disease prevention, and disease management education.
• Maintains flexibility in scheduling to meet clinic demands.

• Assists patients in developing self-management goals and evaluates ongoing progress with the interdisciplinary team, coordinating follow-up as needed.
• Accesses appropriate resources inside and outside the organization to meet patient needs.
• Demonstrates awareness of cultural, ethnic, gender, sexual orientation, and racial differences that may impact outcomes.

• Experience with documentation in an Electronic Medical Record.
• Proficiency in computer word processing and database applications.
• CPR certification by scheduled start date.
• Flexibility and adaptability to a changing environment.
• Ability to prioritize competing responsibilities.

• Required:
  
  Graduate from an accredited School of Nursing;
  Current Maryland Nursing License.
• Preferred:
  One year of nursing in an ambulatory or acute care setting; BSN.
• Significant related experience with populations served may substitute for above requirement.