Care Manager RN or LPN

JOHNSON HEALTH CENTER•Madison Heights, VA

10d•$24 - $33•Hybrid

About The Position

The Care Manager (CM) collaborates and communicates with patients, families, and other JHC healthcare team members to promote and support a patient-centered model of care. The CM, as part of the patient care team, will assess, plan, coordinate, and evaluate patient needs to create an agreed-upon plan of care to prevent disease exacerbation, improve health outcomes, increase patient engagement in self-care, decrease patient risk status, and minimize hospital and emergency department (ED) utilization.

Requirements

Must be licensed with the Virginia State Board of Nursing with a current RN or LPN license in good standing.
Ability to work a typical medical clinic schedule.

Nice To Haves

Experience in care management in a community-based setting is preferred but not required.
If currently certified as a Certified Care Manager (CCM), maintains CCM status as directed by the governing agency, and maintains the appropriate continued education criteria.

Responsibilities

Works with care team providers to identify higher-risk patients with complex medical, behavioral, and or psychosocial needs or issues (such as those having multiple diagnoses or medications, chronic illnesses, complicated treatments, or multiple providers) to educate those patients regarding their health conditions and treatment care plans and assist them with care coordination needs.
Advocates for health literacy, patient involvement, and self-management; educates patients to empower them to be active participants in their health care and treatment options by providing information and collaborating with patients regarding their health care needs.
Collaborates with medical care team providers to develop and implement care plans that involve patients, caregivers, and family to meet health care needs. Monitors adherence to individualized plans of care.
Manages patient caseload based on the acuity level of follow-up.
Promotes wellness through one-on-one education by identifying barriers to care and assisting with lifestyle changes.
Responsible for building one-on-one rapport with patients to improve patient engagement and self-care management.
Monitors ED and hospital discharge reports to assist with the coordination of care and Transitional Care Management after discharge. Assesses discharge information and connects the patient with healthcare professionals; provides education and support regarding treatment plans and medication adherence.
Utilizes clinical skills, as needed, to prioritize and intervene effectively to help keep patients medically stable and provide education and guidance with scheduling of appointments based on current health status and needs.
Performs ongoing assessment of patient needs and individualized care plan by having direct patient and/or patient representative contact (face to face or telephone) and collaboration with medical provider staff to address gaps in medical care through patient outreach, education, and coordination of care.
Serves as a resource for Care Management Coordinators by providing training and guidance in addressing individual patient needs.
Educates clinical staff regarding individual patient issues and barriers to care, general health risk management, and population health issues.
Participates in patient care team meetings to foster a team-based, collaborative environment regarding patient-centered care and workflow processes.
Facilitates patient education programs that help to proactively address preventable health conditions and to manage existing chronic health problems. Collaborates with provider care team members to identify patients who may benefit from participation in different educational programs.
Works with the Director of Population Health to identify center-wide quality of care issues and improve work processes.
Other clinical duties and responsibilities assigned by the Director of Population Health.
Staff members will abide by the Code of Conduct as documented in the Corporate Compliance Manual.
Must demonstrate a personal and professional commitment to Johnson Health Center and its mission.
Treats all patients and staff with dignity and respect, mindful of the cultural differences of the diverse population we serve.
Management may modify, add, or remove any job functions as necessary, or as changing organizational needs require.