Ambulatory Care Manager - RN - Georgia Heart Institute GHI - FT Days

Northeast Georgia Health System•Gainesville, GA

About The Position

The RN Care Manager will assist NGPG Providers in applying systems, science, incentives, and information to improve medical practice and patient care, eliminate duplication, and reduce the need for medical services by helping patients and their support systems in managing medical conditions more effectively. The RN Care Manager will: independently, and in collaboration with providers, identify populations with modifiable risks; align care manager services to the needs of those patients, and implement interprofessional team-based approaches to care. The RN Care Manager will provide those services determined to assist patients in achieving an optimal level of wellness and improve coordination of care while providing cost effective, non-duplicative services. The primary responsibility of the RN Care Manager is to assist in the identification and management of NGPG patients with complex health care needs. Care management services may be provided in a variety of settings including in-person, face-to-face encounters, by telephone, or electronic encounters such as telehealth visits. Primary areas of focus will include management of patients with multiple chronic conditions, including those complex health care needs identified by NGPG providers and managing transitions of care. Clinical care such as medication reconciliation, assessment of adherence to treatment plans, and the identification of adverse events can facilitate intensified treatment and/or mobilize additional patient support.

Requirements

Current Georgia RN license required.
Current BLS certification required or must be obtained within 30 days of hire.
Associates Degree.
A minimum of three (3) years experience as a licensed registered nurse.
High energy and ability to function effectively in a dynamic work environment
Strong organizational and interpersonal skills; able to work effectively in a team environment
Excellent written and verbal communication skills
Strong analytical and problem-solving skills; ability to review reports and complete data validation
Excellent understanding of medical terminology and disease states
Able to interpret complex regulations
Maintains current continuing education appropriate to care management
Demonstrated expertise with Microsoft Excel and reporting databases

Nice To Haves

Bachelors and/or Masters Degree.
A minimum of one (1) year experience providing care management within a primary care setting.

Responsibilities

Collaborates with providers in promoting the delivery of high quality medically appropriate care and services using fiscally responsible strategies.
Uses the nursing process to assess, plan, implement, and evaluate patient care and the use of resources.
Assists in the development, implementation, and analysis of a process for providing outreach to patients with identified care opportunities including, but not limited to, non-compliance, and maintaining clinical markers (e.g., blood pressure, HbA1c) within normal range.
Monitors the quality of care to ensure all aspects of services are safe and appropriate.
Assists in the continuous identification, stratification, and prioritization of patients at highest risk who offer the greatest potential for improvements in health outcomes.
Use the EMR and other methods to facilitate care coordination and effective communication with patients and outreach to them.
Incorporates clinical and non-clinical sources of information in identifying those patients who will most benefit from care management services.
Use timely, all-inclusive team communication and collaboration on patient assessments, care planning, and interventions.
Effectively uses the following tools/strategies that include, but are not limited to: health risk assessments, predictive models (algorithm-driven models that use multiple inputs to predict high-risk opportunities for case management), surveys (e.g., PHQ-9, Short Form 12), case findings (e.g., chart reviews, surveys), referrals (from patients, providers, community).
Tailors interventions that are multi-faceted, improve quality and cost effectiveness to meet the patient's need while respecting the patient's role as a decision maker in the care planning process.
Effectively uses the following tools/strategies that include, but are not limited to: evidence-based guidelines and practices, interactive care plan developed based on patient-set priorities where applicable, collaboration with multidisciplinary care teams, meet medical home (PCMH) requirements, physical/behavioral health integration, and patient self-management education and training.
Effective and timely adherence to disease specific, evidence based guidelines for all chronic conditions as well as preventative and curative care measures.
Improves overall patient care metrics as set by evidence practice medicine and recommended guidelines that are widely set for disease state/conditions that result in most health care expenditures as revealed in CMS chronic conditions literature and/or NGPG/NGHS cost data (i.e., heart failure, diabetes, hypertension, COPD/Asthma, pneumonia, depression and stroke). Focus should minimally cover those patients with 4 or more chronic conditions.
Effectively and timely inform patients about their care planning and facilitate interaction among applicable care team members through application-based secure messaging, assessments, care planning and associated activities, and education.
Maintains awareness and understanding of patient resources from the NGHS, NGPG, the community, and payors to support care management, care coordination, and transitional care.
Anticipates needs of the patient population, identifying and developing programs to support care management, patient education and self-management activities.
Demonstrates reduced emergent/urgent care utilization and acute care readmissions, improved medication compliance, and adherence to diet/prescription regimens managed patients.
Assists in building an evidence base in terms of what works for complex and special needs populations through careful and consistent evaluation, measurement, testing, and analysis of interventions intended to improve quality and efficiency.
Actively participates in weekly collaborative group rounds geared towards identifying problematic cases, obtaining group feedback for recommended interventions and/or sharing impactful recommendations taken, identifying common themes for process improvement, development of protocols or pathways, standing orders, and/or patient self-management tools.
Develops, implements and oversees protocols and processes for assessing change readiness, needs assessment, and developing individualized care plans.
Collaborates with patients, physicians, and other care team members in assessing patient achievement towards meeting goals and with payer case managers when required to identify and obtain approvals for required services.
Maintains current awareness and understanding of quality measures (e.g., HEDIS, ACO, pay for performance) and measures related to efficient utilization and cost.
Participates in the development/review/revision of standard work and related policies and/or procedures for Care Manager services.
Assists in identifying opportunities for system-collaboration, patient education materials, and/or other programs designed to meet patient population needs.
Assists in the identification of population health circumstances where standing orders do not exist, or exist but are not consistently utilized, for improving patient care outcomes.
Attends meetings with payors when patients being managed are discussed.
When requested, be cross-trained to support hospital-based care managers in their absence with the primary focus being the facilitation of the transition of care process for admitted patients.
Other duties as assigned.