RN Nurse Care Manager

Responsibilities

• Coordinates care services with pod leader to ensure patients have access to a comprehensive set of services tailored to their needs.
• Collaborates with the care team to develop and manage personalized care plans, address care gaps, and engage with other resources to ensure access to care.
• Coordinates the transition of care for patients throughout the continuum to ensure patient needs are met and avoidable hospital admissions do not occur.
• Serves as co-chair of the pod alongside the pod leader, focusing on driving and prioritizing patient needs to improve patient outcomes.
• Prioritizes patients based on the severity and urgency of their conditions to ensure the most critical cases receive immediate attention.
• Reviews medical records to identify gaps in care and coordinates services with the care team to manage these issues.
• Updates patient care plans regularly.
• Performs thorough nursing assessments via telephone to maximize or improve current health outcomes.
• Provides education to patients and/or their caregivers on disease education, medication, health maintenance, and disease prevention to promote self-management and improve health outcomes.
• Demonstrates strong clinical skills, critical thinking abilities, and effective communication in interactions with patients, caregivers, providers, fellow care team members, etc.
• Documents necessary interactions, assessments, updates, etc. in patient’s medical records according to processes and guidelines.
• Serves as liaison between patients, providers, resources, etc. to ensure seamless care delivery.
• Facilitates communication of patient status and plan of care during transitional experiences such as home to hospital, hospital to post-acute care and back to home.

Qualifications

• Active Registered Nurse License
• 2+ years of care management experience in community, health plan or hospital systems
• Strong clinical skills and proactive thinking
• Effective communication skills
• Ability to perform extensive telephone assessment
• Knowledge of Medicare regulations and home care and hospice standards
• Experience with small group presentations and teaching/training
• Excellent interpersonal and written/verbal communication skills
• Working knowledge of computer programs (email, Word, Excel, PowerPoint, etc.)
• Manages time effectively to ensure all duties and documentation requirements are completed in a timely manner