TCHP Care Manager-RN - Ft Wright Care Management - Full Time - Days

Responsibilities

• Serve as a clinical care management resource for providers and clinical teams
• Maintain an assigned caseload in accordance with departmental policies
• Identify, enroll, and manage patients in Transitions of Care and Chronic Disease Management programs
• Utilize Motivational Interviewing techniques to engage and activate patients in self-management of chronic conditions
• Conduct comprehensive assessments to identify clinical, psychosocial, and social determinants of health
• Develop, implement, and review individualized care plans in collaboration with the care team
• Perform medication reconciliation and teach-back to ensure patient understanding and adherence
• Collaborate with PCPs, specialists, hospitalists, and other providers to implement patient-centered care plans
• Coordinate care transitions following inpatient or emergency department encounters to promote continuity of care
• Conduct patient outreach per established protocols and document appropriately in the electronic medical record
• Identify, initiate, and track referrals to internal services and community resources
• Education and Training: BSN preferred, Certified Case Manager (CCM), Accredited Case Manager (ACM) or other certifications related to case management/care management
• Experience: Minimum of 5 years of nursing experience (care management or ambulatory experience preferred)

Qualifications

• Licenses & Certifications: Current Registered Nurse (RN) license in the State of Ohio, with multi state licensure required
• Education: BSN preferred
• Experience: Minimum of 5 years of nursing experience (care management or ambulatory experience preferred)
• Skills: Strong problem-solving and critical-thinking skills, ability to prioritize workload and manage multiple demands, proficiency in basic computer functions and electronic medical records, excellent written and verbal communication skills, ability to collaborate effectively within an interdisciplinary team, demonstrated respect and sensitivity to cultural differences
• Other: Knowledge of and alignment with the network’s mission, goals, and values