Clinical Care Manager

Primary Function

The incumbent performs nursing procedures to patients of all ages independently within the framework of established policy. The Registered Nurse is a licensed professional nurse responsible for assessment of patients, development, implementation and evaluation of a patient plan of care; administration of therapeutic measures; teaching and counseling of patients and families; and participating in the development of nursing policies and procedures and quality assurance standards.

Job Description

• Utilizes best practice models to identify, incorporate or develop best practices for panel management.
• Collaborates with other teams to share and establish best practice for health promotion and disease prevention strategies.
• Manages panel by addressing and resolving acute care needs and chronic care needs through a team-based approach.
• Incumbent will be responsible for leading their pod and assisting the Primary Care Provider in panel management that results in meeting facility, national, and regulatory quality indicators.
• Utilizes iCare to track, monitor, and assure the appropriate follow-up of clients targeting specific indicators.
• Utilizes the care management platform for documentation of care management functions such as a care needs screening, Comprehensive assessment, and care planning. Also utilizes the dashboards, within the care management platform for population health and related interventions and innovations.
• Utilizes NC Health connects for information gathering and data collections for management of care needs or gaps in care.
• Coordinates and follows up on referrals to outside specialty providers, recent ED visits, and ICC visits. Emphasis is placed on ensuring treatment notes are available to the PCP timely.
• Participates in the continued development of the role of Case Management in the Patient Centered Medical Home (PCMH) and Advanced Medical Home (AMH and AMH+).

Responsibilities

• Provides standard nursing care for patients throughout the age continuum.
• Develops implements and evaluates care plans.
• Promotes health care outcomes with currently accepted clinical practice guidelines.
• Provides patient education, advice and information on health assessment, disease processes, medications, treatment plans and available community resources.
• Affords assessments for health prevention, health promotion, restorative, and health maintenance needs.
• Plans patient care according to individual assessed patient needs and established hospital policies and procedures.
• Functions as charge nurse when assigned by the Outpatient Administrator; assigns nursing staff according to staff competency and patient complexity and provides technical supervision for staff members, including reviewing procedures; anticipates problems and acts to resolve problems.
• Develops individualized plan of care with input from the patient, patient’s family, pod members, and anyone else the patient requests to be included for those patients considered “high risk.”
• Develops expected patient outcomes that are observable and within an adequate period, and are congruent with the patient’s present and potential physical capabilities and behavioral patterns.
• Implements nursing care according to the established health care plan.
• May be required to change work schedule to assist in covering for periodic “late clinics.”
• May be subject to on-call and callback.
• May be required to rotate between nursing departments including inpatient, satellite clinics, and the emergency department.
• Participates in cross training of services within the nursing department.
• Performs nursing interventions including, but not limited to:
  • Detects changes in the patient’s condition and takes appropriate action.
  • Recognizes, identifies and interprets serious situations and immediately decides proper action.
  • Initiates appropriate resuscitative measures in an emergency.
  • Initiates appropriate action when safety measures are required to protect patients.
• Documents observations, nursing interventions, patient progress, needs, treatments, diagnoses, possible side effects of treatment, teaching, patient response, effectiveness, complications and communicates information to the physician, co-workers and other health personnel.
• Administers and documents medications per manufacturer guidelines, hospital policy and established protocols and according to State Board of Nursing regulations. Documents all known drug allergies on the medical record and according to protocol.
• Affirms that all medications, treatments and tests are done appropriately and in a timely manner, detects, and reports medication errors.
• Provides counseling, teaching, and anticipatory guidance to patients and families on preventive, curative and rehabilitation measures involved in health care. Documents all patient education activities within the patients/family’s level of understanding.
• Provides guidance, leadership, and training to other nursing personnel.
• Coordinates health care needs through referrals to support services, community, and tribal resources to promote continuity of care.
• Maintains a safe environment through the practice of Universal Precautions and Body Substance Isolation, medical waste/chemical management and containment. Isolates infected patients. Cleans patient contact areas and equipment according to policies and OSHA regulations.
• Participates in the development and implementation of performance improvement activities. Identifies and reports risk management issues.
• Assures that all supplies are adequate and appropriate and ensures proper functioning of all medical equipment.
• Maintains cleanliness and orderliness of work areas.
• Promotes patient advocacy and confidentiality.
• Serves on Committees as appointed.
• Maintains and promotes positive and constructive communications and activities within Nursing services, other departments, tribal, and community agencies for purposes of coordinating and understanding of goals and objectives relevant to the population served.
• Functions appropriately during disasters.

Qualifications

• Bachelor or Associate Degree in nursing from an accredited program required.
• Minimum of two years of nursing experience preferred.
• Applicant must have an unrestricted valid Registered Nurse license within the state of North Carolina or a state that is accepted as reciprocity.
• Current Basic Life Support (BLS) minimally required. Can be acquired through the facility within 6 months following appointment to position.
• Applicant must have a valid North Carolina driver’s license.