Nurse Care Manager

About the Role

The Nurse Care Manager provides professional, patient-centered nursing care in the ambulatory setting in accordance with the multi-disciplinary plan of care and established policies and procedures, under the supervision of the Lead Nurse. Provides direct nursing and telephonic services to patients and families in accordance with the standards of practice for Ambulatory Care Nursing.

Responsibilities

• Utilizes assessment skills to evaluate patient needs and formulate a plan of care as part of the multi-disciplinary care team.
• Revises outcomes and interventions based on results of ongoing evaluation, collaborating with both the patient and members of the care team.
• Facilitates individual or group nursing visits with patients to address chronic illnesses, providing education about management and treatment of disease as needed.
• Identifies patients at risk for poor outcomes and those who may require more intensive services; provides additional outreach and frequent follow-up (by phone and in-person) to this population.
• Provides Complex Case Management, including chronic disease case management, critical diagnosis care coordination, transition care management, high-risk clinical tracking, complex medication management, and system utilization to appropriate patients.
• Provides medication reconciliation and adherence counseling, while assessing patient knowledge and barriers to adherence and self-care.
• Triages patients during walk-in/same-day clinic.
• Collaborates with the multi-disciplinary team to address both physical and psychological aspects of health to provide care for the whole patient.
• Works with the Transition of Care Team to ensure safe and effective transitions of care.
• Collaborates with providers during appointments or in nursing visits for education on health promotion, disease prevention, and/or management of disease.
• Assists patients in the development of self-management goals, evaluates ongoing status of goals along with other members of the interdisciplinary care team, and coordinates follow-up as needed.
• Accesses appropriate resources inside and outside the organization to meet the needs of the patient.
• Demonstrates awareness of cultural, ethnic, gender, sexual orientation, and racial differences and their potential to impact patient outcomes.
• Flexible in scheduling to meet the demands of the clinic schedule.

Requirements

• Graduate from an Accredited School of Nursing.
• Current Maryland Nursing License.
• CPR certified by scheduled start date.
• Ability to work with computers in word processing and database applications.
• Must be flexible and adapt to a changing environment.
• Able to prioritize competing responsibilities.

Qualifications

• Preferred: One year of nursing in an ambulatory or acute care setting; BSN.
• Significant related experience with populations served may substitute for the above requirement.
• Experience with documentation in an Electronic Medical Record.