Care Manager Registered Nurse

Responsibilities

• Facilitates communications among patient/family, multidisciplinary team, medical management team, community resources, and other disciplines to anticipate, identify, evaluate, and resolve potential barriers and constraints to timely care delivery.
• Interprets multiple contracts and contractual obligations to enable the care management team to achieve maximum clinical and financial outcomes.
• Collaborates with patient/family and inter-professional team (primary care, hospital care, post-acute care managers, and other care partners) to deliver quality, efficient, and cost-effective healthcare services, either embedded in a provider office or telephonically.
• Uses evidence-based approaches to increase patient and family activation and engagement in their own care; partners with patient and family to develop SMART (specific, measurable, attainable, relevant, time-bound) goals as appropriate to the population.
• Assists in the development, procurement, and adoption of patient self-management educational resources.
• Identifies potential barriers to learning and/or optimal care delivery; reports abnormal findings to the responsible provider/care team and collaborates to develop a plan.
• Independently manages care management caseload according to department expectations, ensuring timely completion of tasks and documentation related to MCO, regulatory, and contractual requirements.
• Partners with identified at-risk patients throughout diagnosis, treatment, and follow-up to deliver continuity of care; anticipates patient needs, recognizes changes in status, and prioritizes care based on essential patient needs.
• Coordinates patient information and communication among patient/family, referring/accepting facilities and physicians, community caregivers, and other members to ensure smooth transitions of care.
• Coordinates referrals to internal departments and/or external community resources as necessary.
• Demonstrates knowledge and skills necessary to provide age-appropriate care, including principles of growth and development over the life span, and interprets patient data to meet age-specific needs as outlined in departmental policies and procedures.

Requirements

• Registered Nurse license issued by the state in which the team member practices.
• Bachelor’s Degree in Nursing or related field.
• Typically requires 5 years of experience in clinical nursing or 1-2 years of care management experience.

Skills

• Applicable certification is encouraged.
• Self-directed with the ability to work independently and within a team environment while meeting the needs of external and internal partners/customers.
• Excellent oral, written, and interpersonal communication skills.
• Strong critical thinking, problem-solving, and organizational skills.
• Ability to work productively in a complex environment with multiple changing priorities.
• Demonstrated ability to collaborate effectively with physicians and other healthcare professionals.
• Proficient in computer/Microsoft Suite and previous Epic EMR experience.
• Ability to handle multiple responsibilities simultaneously.

Physical Requirements and Working Conditions

• May require travel between clinic sites, including exposure to road and weather conditions.
• Manual dexterity required for operating computers and calculators.
• Visual acuity required for reviewing written documents, computer screens, and medical records, and for recording information accurately.
• Clear oral communication and hearing acuity required for receiving instructions and conversing on standard telephones.
• Functional speech and hearing to allow effective telephone communication.
• Exposure to normal office environment, including usual hazards related to operating electrical equipment.
• Operates all necessary equipment to perform the job.