The RN Care Manager develops and implements patient-centered care plans to improve health outcomes and reduce costs. Responsibilities include providing education on chronic disease self-management, coordinating care transitions, and addressing socio-economic barriers to health.
Requirements summary
Candidates must hold an active, unrestricted RN license and a current BLS certification. A valid driver's license is required for travel, along with proficiency in EMR systems and strong communication skills.
professional certificateCare PlanningPatient EducationMicrosoft OfficePatient OutreachElectronic Medical RecordsInterdisciplinary CollaborationClinical AssessmentTelehealthCare ManagementCase PrioritizationChronic Disease ManagementPatient Coaching
Job description
Proposed Schedule
40 hours per week.
Monday-Friday 8am-4:30pm.
Please note
This position will also be required to float to our Salem Family Health Center.
The RN Care Manager is an integral part of the patient’s care team, enhancing primary care and providing an array of services to the patients of the network and support to the primary/specialty care settings. These services include but are not limited to: education, coordination, coaching, transfer of self-management skills, and addressing barriers (including socio-economic). Guidance will be provided to the patients and families for the purpose of improving the health of our populations, improving the quality of care provided and decreasing overall costs. Integrated comprehensive patient-centered care plans will be developed alongside the patient, resulting in improved patient outcomes. Care management activities will occur onsite in health centers, via telehealth, and/or occasionally at the patients’ home, hospital or other community setting.
Provide outreach, information, guidance, and education to the patient and/or family, primary care providers and other members of the care team for appropriate healthcare utilization, chronic disease (e.g. diabetes, hypertension) self-management skills, effective care transitions, assessment and elimination of barriers, including socio-economic barriers, promoting wellness and preventative care measures and enhanced patient-provider communication
Develop individualized, goal-oriented, patient-centered care plans that promote positive outcomes and address physical health, mental health and socio-economic barrier.
Maintain an ongoing responsibility for assigned caseload by prioritizing referrals and activities according to intensity, needs and required follow-up
Provide appropriate teaching, information, instruction and referral services to patients managing various chronic health conditions on-site at the health center, via telehealth, and/or in a home setting
Assess, identify, and close clinical and non-clinical gaps in patient care
Collaborate with health center care team to review results from bloodwork and other tests and provide patient education and follow-up as needed.
Demonstrate knowledge in medical care; such as diagnostic procedures, medication, symptoms, and other treatment-related therapies
Support non-clinical care management team members by providing supplemental patient education through patient outreach
Conduct regular follow-ups with patients to evaluate progress, promote continuity of care, and ensure improved health outcomes
Complete annual care management competencies and any other relevant competencies/trainings as needed
Competent in coaching patients/caregivers on how to obtain a blood glucose level for the purpose of self-management and when to report concerns to health center care team
Competent in coaching patients/caregivers on how to properly self-administer insulin via pen cartridge, and when to report concerns to the health center care team
Work closely with the care management team and build efficient and effective relationships among care team members, including outreach to external organizations that support a positive outcome for patients
Recognize the patient as a contributing member of the clinical team
Serve on network-wide initiatives that support the mission, vision and core values.
Provide any other services as directed by HHHN to ensure proper care and treatment to the patient and/or families.
Maintain accurate and timely documentation within multiple concurrent platforms
Qualifications
Active, unrestricted RN license in the state of practice
Current BLS certification
Applied professional experience in case (care) management and/or social work preferred.
Experience working in fields of Health care, behavioral/mental health, substance/alcohol abuse preferred
Must have a valid driver license and be able to travel throughout the Network
Must have strong verbal and written communication skills
Proficient computer competencies including Microsoft applications, electronic medical records and related databases
Must be well organized and can effectively manage multiple cases and projects
Must be self-directed, detail-oriented and motivated
Must be able to work independently as well as collaborate and communicate effectively with colleagues, supervisors, service delivery partners, other health care professionals and co-workers to build and maintain effective dynamic professional team relationships
