Clinical Corp Shared Services - Chronic Disease Management Nurse

The Chronic Disease Management Nurse is responsible for providing care management services to patients with complex chronic medical conditions. The patient population may include those with socioeconomic and mental health co-morbidities. The goal of the program is to assist these patients to achieve optimal health and/or independence in managing their care. To achieve this goal, the disease manager will demonstrate and apply knowledge of the philosophy/principles of comprehensive care management, patient centered, culturally sensitive care coordination and management of complex patients.

This position will work closely with members of the care team to achieve goals/objectives, standards of performance, regulatory compliance, and quality patient care.

• Assess the physical, functional, social, psychological, environmental, learning and financial needs of patients.
• Identify problems, goals and interventions designed to meet patient’s needs surrounding management of complex chronic medical conditions, including prioritized goals that consider the patient/caregivers goals, preferences and desired level of involvement in the case management plan.
• Create care plans including problems, goals and interventions designed to meet patient’s needs.
• Implement and monitor the care plan to ensure the effectiveness and appropriateness of services
• Evaluate patient’s progress toward goal achievement, including identification and evaluation of barriers to meeting or adhering to their medical plan of care, and systematically reassess for changes in goals and/or health status.
• Intensive disease state education, direction, and support in achieving member self-care competence.
• Utilize motivational interviewing skills to build patient engagement in care management plan of care.
• Provide education, information, direction and support related to care plan goals.
• Perform care management following the nursing process and standards of practice established by the Case Management Society of America (CMSA).
• Act as a patient advocate and assist with problem solving and addressing any barriers to care or compliance with care plan.
• Collaborate with the Social Worker by referring patients for SDOH needs and community resources and monitoring outcomes to ensure that services are being delivered, and patient needs are being met. Engage in professional development activities to keep abreast of care management practices and patient engagement strategies.
• Establish a trusting relationship with patients, their families, and/or caregivers.
• Collaborate with clinical staff and other care team patients to achieve patient goals.

• Communicate telephonically with hospital case managers, physical therapists (PT), social workers, patients, and families/caregivers to facilitate a safe discharge plan.
• Willingness to travel up to 10-20% locally to Arch Well Health centers to enhance collaboration with PCP and other members of the care team and/or engage with members face-to-face.

• Subject matter expert in chronic medical conditions such as Chronic Lung Disease, Heart Failure, Diabetes, and Chronic/End Stage Kidney Disease.
• Ability to plan, implement and evaluate patient specific care plans.
• Experience with monitoring, assessing, recording, and adjusting plan accordingly.
• Excellent verbal and written communication (including documentation) skills.
• Excellent relationship management with patients, families, and care providers.
• Strong organizational skills.
• Strong interpersonal communication skills with exceptional active listening abilities.
• Highly empathetic, non-judgmental, and open-minded.
• Experience in a collaborative team environment.
• Self-starter, critical thinker, and owner.
• Demonstrated ability to work…