Nurse Care Manager

About the role

30 hours a week (6-8 hours a day) as scheduled. The Nurse Care Manager reports to the Director of Quality Programs for the Division of Kidney Disease and Hypertension. Under the general supervision of the Director of Quality Programs for the Division of Kidney Disease and Hypertension, Practice Physician Medical Director, and departmental policies, the Nurse Care Manager works on an interdisciplinary healthcare team in a specialty care setting to conduct direct patient care and quality improvement activities. He/she will be part of a program charged with implementing strategies to meet specified quality measures. The Nurse Care Manager is responsible for providing comprehensive screenings, assessments, care coordination services, disease education, and self-management support to patients with chronic kidney disease. The Nurse Care Manager is integrated into the office-based healthcare team to promote patient-centered care, frequent contact with primary care providers, and dialysis centers. The Nurse Care Manager has a key role in educating patients about kidney replacement therapy, transplant, palliative care, hospice, and preparing the patient for their chosen modality. The Nurse Care Manager is also responsible for preventing hospitalizations in the dialysis population and patients identified as at risk for rapid progression of advanced kidney disease. Patient care activities will be conducted in person as well as via telehealth.

Responsibilities

• Works collaboratively with the care team to identify and case manage patients with a high risk of adverse health outcomes ensuring open communication patient status with providers and office staff.
• Sets up and implements patient-centered care 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 chronic kidney disease, hypertension, diabetes, and depression 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 timeframes.
• 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,