Care Manager -- RN

About the position

The Care Manager (CM) works with the patient population and other JHC staff to support a patient centered, model of care. The CM will assess, plan, facilitate, coordinate, and evaluate patient needs and, with patient consent, create an agreed upon plan of care to facilitate medical self-management and wellness.

Responsibilities

• Identifies patients who have complex medical issues in order to assist and educate patients regarding their conditions and treatment plans, and aid in care coordination.
• Advocates for patients' health literacy and medical self-management; educates patients to empower them to be active participants in the health care and treatment options by informing and collaborating with patients regarding their health care needs.
• Develop and implement care plans that involve patients, caregivers and family to meet health care needs. Monitors adherence to individualized plan of care.
• Manages patient caseload based on acuity level of follow-up.
• Promote wellness through one on one education by identifying barriers to care and assisting with lifestyle changes.
• Responsible for building one on one rapport with patient to improve patient engagement and self-care management.
• Monitors ER/Hospital discharge reports from the hospital to assist with coordination of care and Transitional Care Management after discharge. Assesses discharge information and connects the patient with healthcare professionals; educates and supports treatment regimen adherence and medication management.
• Performs medical triage as needed to provide appropriate guidance through education and scheduling of appointments based on current health status and needs.
• Performs on-going assessment of patient needs and individual care plan by having direct patient/patient representative contact and confers with medical staff to address gaps in medical care through patient outreach, education and coordination of care.
• Serve as a resource for Care Management Coordinators by providing training and guidance in addressing individual patient needs.
• Educates medical staff regarding individual patient issues and barriers as well as general health risk management and population issues.
• Participates in patient care team meetings to maintain patient-focused care and work flow processes.
• Facilitate patient education programs to proactively address preventable health problems and manage existing chronic health problems and works with provider care teams to identify patients who may benefit from different educational programs.
• Works with the Director of Care Management to identify center-wide care issues and improve work processes.
• Other clinical duties and responsibilities as assigned by the Director of Care Management.

Requirements

• Must be licensed with the Virginia State Board of Nursing with a current RN license.
• Minimum of 3-5 years' RN experience.
• Must have graduated from an accredited nursing program.
• Certified Care Manager (CCM) is preferred.
• If certified, maintains Certified Care Manager status as directed by governing agency and maintains the appropriate continued education criteria.
• Ability to work a flexible schedule.