Nurse Care Manager

Major Duties And Responsibilities

• Analytical and Critical Thinking
  • 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, provides 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.
• Teamwork
  • Collaborates with multi-disciplinary team to address both physical and psychological aspects of health to provide care for the whole patient.
  • Works along with the Transition of Care Team to ensure safe and effective transitions of care.
  • Collaborates with provider during appointments or in nursing visit for education on health promotion, disease prevention and/or management of disease.
  • Able to prioritize competing responsibilities.
• Patient Focus
  • Assists patients in the development of self-management goals, evaluates ongoing status of goals along with other members of the interdisciplinary care team; coordinates follow-up as needed.
  • Accesses appropriate resources inside and outside the organization to meet the needs of the caller/patient.
  • Demonstrates awareness of cultural, ethnic, gender, sexual orientation and racial differences and their potential to impact patient outcomes.

Skills And Abilities

• Experience with documentation in an Electronic Medical Record
• Ability to work with computers in word processing, and database applications preferred
• CPR certified by scheduled start date
• Must be flexible and adapt to a changing environment

Education And/Or Experience Required

• Graduate from an Accredited School of Nursing
• Current Maryland Nursing License

Preferred

• One year of nursing in an ambulatory or acute care setting
• BSN
• Significant related experience with populations served may substitute for above requirement