Nurse Care Mgr

The Nurse Care Manager reports to the Director of Clinical Operations and the Administrative Director for Primary Care and Clinical Integration. Under the general supervision of the Practice Physician Medical Director, and departmental policies, the Nurse Care Manager is integrated into the practice-based healthcare team to work in partnership to promote patient-centered care, maintaining frequent contact with the primary care providers and medical home team members.

The Nurse Care Manager will enhance delivery of care and promote care while actively participating in interdisciplinary patient-centered team meetings and huddles/collaborative care rounds. All essential functions performed in this position reflect the age specific needs of the patients.

Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another.

• Works collaboratively with the care team to identify and case manage patients with a high risk of adverse health outcomes in a primary care setting ensuring open communication patient status with providers and office staff.
• Sets up and implements primary care medical home model and administers evidence-based healthcare, utilizing innovative thinking and understanding of healthcare delivery system access points and services.
• Facilitates communication between members, providers, and stakeholders to coordinate and implement action plans aimed at improving the patients’ total health and attaining desired patient outcomes.
• Provides comprehensive screenings, assessments, care coordination services, disease education and self-management support with patients who have chronic health conditions, with particular attention to diabetes, depression and coronary artery disease in the office or home setting as needed.
• Provides detailed education to patients about their specific chronic illness, including pathology signs and symptoms, complications and medications used in treatment.
  
  Conducts and/or reviews medication reconciliation and works with provider/team pharmacist as needed to assist with medication management to support patients to enhance medication adherence.
• Works one-on-one with patients meeting individual healthcare needs; develops a plan of care, interventions and treatment goals with patients that promote improved health outcomes and quality of life and reviews with provider and clinical team members.
• Addresses barriers to optimum patient health; advocate for patients to ensure access and timely service delivery across the continuum of care. Ensures safe, effective and efficient care for all patients transferring to home from the Emergency Department; responsible for timely telephonic follow up of complex patients who present to the ED.
• Utilizes behavior techniques, such as motivational interviewing, to assist patients with establishing self-management goals and action plans with time frames.
• Acting as a liaison, coordinates care and performs outreach identifying and utilizing cultural and community resources; providing access to culturally and linguistically appropriate services as needed.
  
  Utilizes an interdisciplinary team approach to address opportunities to plan and coordinate care; acts in a supportive capacity to other team members (medical assistants, patient service representatives, practice managers, providers, etc.) in supporting patients and their treatment plan.
• Utilizes the Electronic Medical Record (EMR), chronic disease registry, and Current Care reporting to prioritize patient follow-up.
  
  Generates quarterly reports on service volume, distribution of patients by plan, and types…