Care Manager RN or LPN

About the role

The Care Manager (CM) collaborates and communicates with patients, families, and other JHC healthcare team members to promote and support a patient-centered model of care. The CM, as part of the patient care team, will assess, plan, coordinate, and evaluate patient needs to create an agreed-upon plan of care to prevent disease exacerbation, improve health outcomes, increase patient engagement in self-care, decrease patient risk status, and minimize hospital and emergency department (ED) utilization.

Essential Duties And Responsibilities

• Works with care team providers to identify higher-risk patients with complex medical, behavioral, and or psychosocial needs or issues (such as those having multiple diagnoses or medications, chronic illnesses, complicated treatments, or multiple providers) to educate those patients regarding their health conditions and treatment care plans and assist them with care coordination needs.
• Advocates for health literacy, patient involvement, and self-management; educates patients to empower them to be active participants in their health care and treatment options by providing information and collaborating with patients regarding their health care needs.
• Collaborates with medical care team providers to develop and implement care plans that involve patients, caregivers, and family to meet health care needs.
• Monitors adherence to individualized plans of care.
• Manages patient caseload based on the acuity level of follow-up.
• Promotes wellness through one-on-one education by identifying barriers to care and assisting with lifestyle changes.
• Responsible for building one-on-one rapport with patients to improve patient engagement and self-care management.
• Monitors ED and hospital discharge reports to assist with the coordination of care and Transitional Care Management after discharge.
• Assesses discharge information and connects the patient with healthcare professionals; provides education and support regarding treatment plans and medication adherence.
• Utilizes clinical skills, as needed, to prioritize and intervene effectively to help keep patients medically stable and provide education and guidance with scheduling of appointments based on current health status and needs.
• Performs ongoing assessment of patient needs and individualized care plan by having direct patient and/or patient representative contact (face to face or telephone) and collaboration with medical provider staff to address gaps in medical care through patient outreach, education, and coordination of care.
• Serves as a resource for Care Management Coordinators by providing training and guidance in addressing individual patient needs.
• Educates clinical staff regarding individual patient issues and barriers to care, general health risk management, and population health issues.
• Participates in patient care team meetings to foster a team-based, collaborative environment regarding patient-centered care and workflow processes.
• Facilitates patient education programs that help to proactively address preventable health conditions and to manage existing chronic health problems.
• Collaborates with provider care team members to identify patients who may benefit from participation in different educational programs.
• Works with the Director of Population Health to identify center-wide quality of care issues and improve work processes.
• Other clinical duties and responsibilities assigned by the Director of Population Health.

Core Values

Staff members must actively demonstrate dedication and commitment to the core values of JHC:

• Respect – We value and respect each patient, their family, ourselves, and each other. Every individual associated with Johnson Health Center will be treated with dignity and respect. We value and respect people's differences, show empathy to our patients, their families and each other, and work collectively to build Johnson Health Center as a health center and an employer of choice.
• Integrity – We are committed to doing the right thing every time. Our actions reflect our commitment to honesty, openness, truthfulness, accuracy and ethical behavior. We are accountable for the decisions we make and the outcome of those decisions.
• Excellence – We will pursue excellence each and every day in activities that foster, teamwork, quality improvement, patient care, innovation, and efficiencies. At Johnson Health Center, our medical, dental, pharmacy, behavioral health, front desk and administrative teams are passionately committed to the highest quality of care for our patients. We continually seek out ways to enhance the patient experience and promote an environment of continuous quality improvement.
• Innovation – We value creativity, flexibility, and continuous improvement efforts. We are advocates and instruments of positive change, encouraging employees to engage in responsible risk-taking and working to make a difference. Out of the box thinking enables us to build on successes and learn from failures.
• Teamwork – We understand that teamwork is the essence of our ability to succeed. We work across functional boundaries for the good of the organization. Our collaborative approach ensures participation, learning and respect and serves to improve the quality of patient care. By focusing on a team-based approach, the expertise of each Johnson Health Center employee is leveraged to optimize the patient experience.

Physical Demands and Working Environment

• Fast-paced office setting with travel to other offices often.
• Lifting and/or exerting force up to 25 pounds occasionally, with frequently moving of objects.
• Work requires speaking, sitting, bending, walking, standing, hearing, and stooping, kneeling, and repetitive motion with certain activities.
• 8 hours of constant computer usage.
• OSHA medium risk position.