RN Care Manager

SUMMARY

This position is responsible for managing high risk, chronic condition patients to promote effective education, self-management support and timely healthcare delivery to achieve optimal quality and financial outcomes. Responsibilities include coordinating patient care to improve quality of care through the efficient use of resources and thereby enhancing quality, cost‑effective outcomes. Acts as an advocate for the individual’s healthcare needs and coordinates care to minimize fragmentation of health‑care delivery systems.

This position is committed to improving the health status of the individual as well as the Primary Health Solutions community.

JOB TITLE: RN Care Manager
DEPARTMENT: Admin
REPORTS TO: Clinical Quality Director
STATUS: Exempt

• Collaborates with providers and practice staff in identifying appropriate patients for care management, utilizing established Care Management criteria. Prioritizes patients according to intensity, need and required follow up.
• Performs initial and periodic holistic assessments for care‑managed population. The assessment includes a systematic and pertinent collection of data about the health status of the patient.
• Formulates and implements a care management plan that addresses the patients identified needs by assessing the patient/family needs, issues, resources and care goals; determining the choices available to individual patients; educating the patient/family on the choices available. Establishes a care management plan that is mutually agreed upon by the health‑care team and the patient/family. Plans will contain specific mutual self‑management goals, objectives, and interventions with the patients are action oriented.
  
  Identifies barriers and empowers patients/families to achieve maximum levels of wellness and self‑management. Involves patient/family in the formation and ongoing evaluation of the plan of care.
• Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, barriers/issues and goals. Monitors and evaluates the progress of the patient.
• Collaborates with the healthcare team to revise the care management plan when changes occur. Initiates discussions with multidisciplinary team regarding patient progress, new needs or problems, etc. Scans for gaps in care to identify patients needing the additional support of care management.
• Identifies social determinants of health needs and effectively utilizes community resources to meet these needs.
• Performs follow‑up calls for patients recently discharged from acute hospitalizations and who are considered high risk for readmission using established criteria. Performs medication reconciliation for these care transitions.
• Collaborates with providers, other healthcare team members (including inpatient facilities, the patient’s payer and health system administrators) to facilitate transitions of care across the healthcare continuum and optimize clinical and financial outcomes.
• Maintains database on care‑managed population. Maintains accurate and timely documentation in the EMR.
• Performs all duties and responsibilities in accordance with basic principles and guidelines of professional nursing. Participates in regular team meetings and appropriate quality and organizational committees. Participates in the orientation of new personnel. Abides by the organization’s compliance program and requirements. Works collaboratively with leadership team to improve and enhance care delivery through the evaluation, development and enhancement of policy and procedures.
• Performs and/or participates in other appropriate projects or duties as assigned.

None.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

RN required. Proficiency in medication indications and side effects.…