Nurse Care Manager

Responsibilities

• Serve as a telephonic care management resource to clinical teams, including:
  • Develop and maintain strong relationships with Patient First Physicians to integrate the care management program into their practices.
  • Work with clinical leadership and the QIC Project Director to define quality measures, establish goals, and develop protocols and point-of-care reminders using nationally recognized, evidence-based care (EBC) quality measures.
  • Work with clinical leadership and the QIC Project Director to improve the effectiveness and efficiencies of clinical practices and processes.
  • Review patient medical records and both internal and external reports to identify and research possible gaps in care.
  • Work with clinical leadership to identify strategies to address and close identified gaps in care at the practice level.
  • Use available resources to actively and efficiently identify patients appropriate for care management.
  • Maximize patients’ health, wellness, safety, and self-care through quality care management, patient satisfaction, and cost-efficiency.
  • Assist center nurses and other members of the health care team by providing advice and handling emergent or urgent calls within the Nurse Care Manager’s scope of professional practice.
• Actively manage an assigned panel of chronic care patients telephonically, including:
  • Develop relationships with patients as an integral member of the health care team.
  • Assess patients’ physical and psychosocial needs, including establishing literacy status and identifying barriers for the patient, family, and caregivers.
  • Educate patients and health care team members on the importance of preventative care and care coordination.
  • Support efforts to ensure a complete health assessment is performed and on file for each identified primary care patient to meet individual payor contractual requirements.
  • Work with patients and their care teams to coordinate change readiness and needs assessment and develop individualized treatment care plans.
  • Monitor and evaluate the effectiveness of the treatment care plan and modify as necessary.
  • Provide expert clinical guidance resulting in transformational changes in patients’ overall wellbeing.
  • Assist patients in setting specific, measurable, achievable, relevant, and time-based (SMART) goals for self-management.
  • Teach patients how to conduct self-management tasks and report abnormal findings to the care team.
  • Promote patient engagement and self-management by involving the patient in activities to improve their health.
  • Document patient self-management measures, create mutually agreed-upon care plans, and report progress toward identified goals.
  • Collaborate with patients, family members, caregivers, physicians, and other care team members to assess progress toward health care goals.
  • Manage various aspects of patient care (e.g., referrals to specialists, hospitalizations, emergency room visits, ancillary testing, and medication reconciliation) and assist in coordination of care.
  • Communicate with patients to ensure compliance with recommendations and follow-up visits.
  • Review documentation from other providers (e.g., hospital discharge summaries), follow up with the patient as necessary, and document conversations and recommendations in the electronic medical record.
  • Follow Patient First protocols when handling urgent and emergent calls.
  • Anticipate the needs of the chronic care patient population and ensure necessary documentation and pre-visit planning is reviewed with the patient when possible.
  • Instruct and encourage patients on the use of the Patient First patient portal.
  • Facilitate communication between members of the health care team and patients in the decision-making process.
  • Assess patient barriers to complete treatment goals through motivational interviewing and assist in mitigating issues and removing barriers to care.
  • Oversee the development, procurement, and adoption of patient self-management educational resources used by primary clinical teams.
  • Collaborate with external case managers for additional services as appropriate.
  • Develop a list of medical supply and community resources available to patients and maintain collegial relationships with frequently used organizations.
  • Work with consulting physicians, hospitals, ERs, and other frequently used health care resources to clarify roles and develop effective and efficient communication.
  • Facilitate, advocate, and intervene on behalf of the patient to ensure successful implementation of the treatment care plan and continuity of care.
• Work as a center staff nurse as directed.

Requirements

• Eighteen years of age or older.
• RN licensure required; BSN preferred.
• Ability to be licensed in all states in which Patient First operates.
• Current CPR, ACLS, and PALS certifications.
• Minimum of three years’ clinical experience in medical/surgical, ER, critical care, and ambulatory care preferred.
• Certification as a Case Manager or experience in Case Management and Primary Care/Patient-Centered Medical Home Care or environment that coordinates care across multiple providers preferred.
• Telephonic triage, coaching, or care coordination experience required.
• Ability to work in a team-oriented environment.
• Highly organized with well-developed oral, written, presentation, and interpersonal communication skills.
• Demonstrates sound judgment and decision-making, problem-solving, and analytical skills.
• Strong professional-level knowledge in comprehensive clinical assessment in the primary care population and chronic disease management.
• Knowledge of psychosocial aspects of chronic illness.
• Experience in quality improvement, quality and efficiency metrics, and data analytics preferred.
• Demonstrated success in influencing patients and providers.
• Experience with medically oriented care plan documentation and ability to develop and implement a plan of care.
• Skilled in active listening, critical thinking, social perceptiveness, active learning, and instruction methods for patient engagement and activation.
• Comfortable managing multiple tasks and continually reprioritizing.
• Ability to delegate and make sound judgments while working with employees and providing medical care.
• Ability to work effectively with all levels of administrative and professional personnel.
• Able to maintain confidentiality with all aspects of information in accordance with organizational and HIPAA policies.
• Proficient computer skills, including experience with Microsoft Word, Excel, presentation preparation, and database management.
• Must be able to hear pages, bells, and phone systems.
• Must be able to sit, stand, and walk for long periods (possibly 4 to 7 hours at a time).
• Ability to travel (including overnight) to attend meetings, conferences, etc., as needed.
• Ability to work extended hours, including nights and weekends, as needed.
• Bilingual is a plus.

Pay

Salary Range: $35.00 - $49.00 per hour, depending on experience.

Benefits

• Health, Dental, and Vision insurance for employees and dependents.
• Disability, Life, and Long-Term Care insurance.
• Employee Assistance Program.
• Flexible Spending accounts.
• 401(k) Retirement Plan (with employer match).
• Paid Annual Leave, Volunteer Time Off Pay, Bereavement Leave, Emergency Leave Bank.
• Overtime Pay, Holiday Pay, Double time compensation for all holidays worked.
• Discounted medical treatment at any Patient First location for employees and immediate family.
• Bonuses include Recruitment Bonus.