Nurse Care Manager

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MEDICAL Full TIme Management Avondale, LA, US

2 days ago Requisition

GENERAL SUMMARY OF DUTIES
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The Nurse Care Manager ensures all patients who require chronic care management receive timely medical services, comprehensive education, intensive care coordination, with self-management support aimed at improving the patient’s health outcomes. Serves as an advocate and point of contact for patients their family and caregivers, providing resources and assistance to access healthcare services offered within the community. The Nurse Care Manager works in collaboration with the multidisciplinary care team to organize and coordinate patients’ care throughout the healthcare continuum.

Serves as a liaison throughout the organization and with external community partners to provide patients, that are high-risk for health deterioration and/or poor health outcomes, with needed services required for health promotion. The Nurse Care Manager ensures that the providers and care team sustains a robust role in the plan of care of high-risk vulnerable patients receiving optimal care which include acute care, chronic disease, as well as preventive care management across multiple healthcare settings.

SUPERVISION

EXERCISED
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Indirectly supervises Care Coordinators.

ESSENTIAL FUNCTIONS
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• Practices and maintains all federal, state, and local regulations, guidelines, protocols, and standards of care ensuring compliance and continuity of patient care.
• Institutes the principles of the Patient Centered Medical Home (PCMH) model, utilizing clinical protocols and tracking tools conjointly, under the direction of clinical leadership.
• Works across the entire organization.
• Work with the care team to provide timely, coordinated, compassionate interdisciplinary care.
• Assists with the coordination of care for patients transitioning to or from other healthcare facilities and/or providers.
• Assesses the patient’s physical, mental, and psychosocial needs.
• Identify and triage high-risk patients based on the severity of disease, self-care limitations, lack of support, severe socioeconomic factors, polypharmacy, and healthcare utilization trends.
• Maintains a registry of high-risk patients with documented completion of measures and interventions.
• Initiates care management by educating and informing patients, their family and caregiver of their treatment plans, ensuring seamless, continuous and comprehensive healthcare based on their need’s assessment.
• Utilizes behavioral strategies to assist patients in adopting healthy behaviors, improving self-care and managing chronic disease(s).
• Communicates consistently with the multidisciplinary care team about the patient’s needs and/or concerns.
• Under the direction of the provider, response to the patient’s request for information regarding their disease process, treatment plan, medications, side effects, etc.
• Under the supervision of the provider, support the patient, their family and caregiver during times of difficult decision-making.
• Coordinates planning sessions with the care team to ensure all disciplines are engaged and involved in the management of patients with poorly controlled medical condition(s), who have been hospitalized and are non-compliant regarding their treatment plan.
• Systematically, logs and tracks patient referrals aimed at risk stratification and treatment plan optimization to achieve patient compliance.
• Assists the Care Coordinators with managing patient referrals, consults, support services, results and reports, notifying the providers in a timely manner for patient follow-up.
• Keeps current with all Electronic…