RN Clinical Care Manager

Responsibilities

• Integrates and coordinates access and utilization management, proactive patient management, care facilitation, and treatment planning functions for the Primary Care Network.
• Carefully coordinates the medical care of high-risk patients identified through health risk assessment/appraisal or physician clinical determination.
• Carries out targeted outreach and follow-up, assisting in care plan development for medically complex patients, and identifies barriers to successful care management.
• Develops and implements population-based strategies to close gaps in medical care for patients with chronic diseases.
• Identifies resources for patient self-management skills.
• Assists in developing and implementing care plans for medically complex patients, ensuring alignment with patient needs.
• Identifies barriers to a successful care management path and develops strategies to overcome them.
• Assists with planning short-range and long-range program goals for chronic disease management.
• Participates in the development of evidence-based protocols, policies, workflows, guidelines, and flow sheets within the medical home model.
• Participates in committees as assigned.
• Keeps abreast of organizational developments and practices that may impact operations by engaging in continuing education, professional organizations, seminars, and relevant literature.
• Coordinates use of clinical and ancillary resources within and outside of the health system to achieve treatment goals specified in the patient care plan.
• Interacts effectively with physicians, home care teams, patients, and their caregivers.
• Holds accountability for patient triage, ensuring appropriate and timely care interventions.
• Adheres to infection control and safety guidelines.
• Ensures compliance with HIPAA, The Joint Commission (TJC), and Occupational Safety & Health Administration (OSHA) regulations and policies.

Requirements

• Bachelor's degree in Nursing or health related field and 3 years of professional nursing experience required
• Or equivalent combination of education and experience
• Experience with ambulatory care in community health, care management, disease management, quality improvement and/or management preferred

Qualifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure, Licensure in NYS upon hire required
• Cardiopulmonary Resuscitation (CPR) current certification upon hire required