The Care Management Nurse provides intervention for patients enrolled in the care management program; develops comprehensive plan of care for patient's individual needs that transition across the health care delivery system.
Accurately gathers and interprets information obtained to identify patients suitable for effective intensive care management intervention.
Develops relationships with patients enrolled in the care management program and competently uses assessment skills to identify physical, psycho-social, financial, and environmental health care needs of the patient.
Assesses and identifies appropriate resource utilization, level of care, and treatment options to develop a comprehensive plan of care that is specific to the member’s individual needs with the goal of optimizing the member’s health status, self-management, and promotion of safe transitions of care.
The care plan will be constructed utilizing evidence-based care guidelines, preventive guidelines, protocols and other metrics in a partnering approach with the patient and clinical team, which will promote and positively impact quality outcomes in a cost-effective manner.
Educates the patient and appropriate ancillary personnel about the health care needs, safety issues and benefits which include patient education tools that can be used by those in the care management program.
Collaborates with the clinical staff in the development and execution of the plans of care and achievement of goals.
Researches, secures, and links resources, services and supports with/for the patient and family.
Coordinates care of patients, focusing in particular on transitions of care across the healthcare delivery system.
Utilizing available electronic tools, such as EMR, to efficiently document assessments, clinical finds, multiple and completed needs, plans of treatment and progress toward goals.
Actively participates in safety initiatives and risk mitigating measures where appropriate and completes all position safety related competencies and requirements on a timely basis.
Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.
Other duties may be assigned as required.
High School Graduate
Bachelor Degree Nursing
Licensed Registered Nurse (LRN) - Multi-State - State Board of Nursing
Must have current active multistate state Register Nurse (RN) license in good standing in state in which you live OR active single state RN license in good standing in the state you will be working with proof of application of a multistate RN license in the state in which you live.
Staff hired prior to 2/1/2024 are required to obtain a multistate state RN license from the state in which they live at the time of their next RN license renewal by 3/31/2026.
Strong computer skills
Efficiently enters information in EMR while interacting with patients telephonically or in person.
Advanced Cardiac Life Support (ACLS) - American Heart Association (AHA)
Basic Life Support Heartsaver (BLS HS) (Non-Clinical) - American Heart Association (AHA)