RN Nurse Care Manager

Essential Duties & Responsibilities

• Coordinates care services with pod leader to ensure that patients have access to a comprehensive set of services tailored to their needs throughout their healthcare journey
• Works collaboratively within 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 accordingly and to ensure that avoidable hospital admissions do not occur
• Coordinates and facilitates High Risk Huddles along with ensuring that follow-up actions are completed
• Prioritizes patients based on the severity and urgency of their conditions to ensure that the most critical cases receive immediate attention
• Reviews medical records to identify gaps in care and coordinate services with the care team to manage these issues
• Regularly updates patient care plans
• Performs thorough nursing assessments via telephone of patients 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 their 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

In this role you may work with. . .

Required Knowledge, Skills and Experience

• Active Registered Nurse License
• 2+ years of care management experience in community, health plan or hospital systems
• Possesses 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
• Exhibits excellent interpersonal skills
• Exhibits excellent written and oral 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

Preferred Knowledge, Skills and Experience

• Bachelor of Science in nursing or related field
• May be required to obtain multi-state licensing
• Strong knowledge of population health, quality measures, care gap closure and value-based care models