Nurse Care Manager

About the role

The Nurse Care Manager works collaboratively with physicians and other members of the health care team to improve the health of patients with chronic conditions or complex needs. This position educates patients and families to help them manage their health care needs. The incumbent facilitates communication, coordinates services, addresses barriers, and promotes optimal allocation of resources while balancing clinical quality and cost management. Scope: Nurse Care Manager-MG works in the ambulatory setting. Patient interactions may be in person, by telephone, or other electronic means.

Responsibilities

• General Case Management: Responds to physician referrals and identifies patients who meet established criteria for care management (e.g., HgA1c > 8, elevated LDL and/or B/P, Mental Health Integration referral, complex resource needs). Works with discharge planners on inpatient units to get the appropriate appointments.
• Patient Evaluation: Assesses family, social, cultural characteristics. Understands communication needs (e.g., vision, hearing). Assesses behavioral and family risk factors. Assesses barriers. Screens for chronic disease (e.g., depression). Reviews patient understanding of medication treatment.
• Coordination of Care: Coordinates with care managers in other settings as appropriate. Provides information on enabling services (e.g., transportation). Maintains list of key community services agencies with contact information. Provides information about recommended or available services and contacts.
• Manage Populations, Disease Registries and Preventive Care: Establishes process to monitor patient adherence to medical plan of care. Focuses on prevention measures consistent with established guidelines and care process models. Reviews and manages quality reports related to chronic disease and prevention. Supports clinicians in achieving quality incentives.
• Team Based Care: Works collaboratively with referring physician and other members of care team.
• Personalized Primary Care: Completes pre-visit planning (review chart before visit, notify patient of tests needed before the visit). Facilitates advanced care planning (Advanced Directives). Establishes a process for reminder letters and phone calls. Supports clinicians and team to achieve personalized primary care goals. Facilitates transitions of care (e.g., unscheduled hospital admissions, emergency department visits, skilled nursing home). Tracks status of critical adult and pediatric referrals. Follows up to obtain report back from referral clinician. In collaboration with clinician, establishes written care plan for patients transitioning from pediatrics to adult. Provides information on health insurance resources. Supervises and supports Health Advocates. Attends clinic team meetings. Assists with scheduling intake.

Requirements

• Current RN license for state in which the nurse practices.
• BLS certification for healthcare providers.
• RNs hired or promoted into this role need to have or obtain their BSN within three years of hire or promotion.
• Three years of clinical nursing experience.

Preferred Qualifications

• Bachelor's degree in Nursing (BSN) from an accredited institution (degree will be verified).
• Experience in case management, utilization review, or discharge planning.
• Ongo