Care Manager RN or LPN

JOHNSON HEALTH CENTER•Lynchburg, VA

5d•$24 - $33•Onsite

About The Position

The Care Manager (CM) collaborates and communicates with patients, families, and other Johnson Health Center (JHC) healthcare team members to promote a patient-centered model of care. As part of the patient care team, the CM assesses, plans, coordinates, and evaluates patient needs to develop an agreed-upon plan of care. The goals are to prevent disease exacerbation, improve health outcomes, increase patient engagement in self-care, decrease patient risk status, and minimize hospital and emergency department utilization. The role includes identifying and supporting higher-risk patients with complex medical, behavioral, or psychosocial needs; educating patients and supporting health literacy, involvement, and self-management; coordinating individualized care plans with providers, patients, caregivers, and families; and monitoring adherence and patient needs. The CM manages a caseload according to acuity, supports wellness and patient engagement, coordinates transitions after hospital or emergency department discharge, and helps patients access appointments and follow treatment plans. The CM also serves as a resource to Care Management Coordinators, educates clinical staff, participates in patient care team meetings and patient education programs, and works with the Director of Population Health on quality and workflow improvements. The position is based in a fast-paced office setting and frequently involves travel to other offices. It requires up to eight hours of computer use and physical activities including speaking, sitting, bending, walking, standing, hearing, stooping, kneeling, repetitive motion, and occasionally lifting or exerting force up to 25 pounds. The role is classified as an OSHA medium-risk position. Candidates must hold a current Virginia RN or LPN license in good standing and be able to work a typical medical clinic schedule.

Requirements

Current RN or LPN license in good standing with the Virginia State Board of Nursing.
Ability to work a typical medical clinic schedule.
Ability to perform the physical activities described, including occasionally lifting or exerting force up to 25 pounds and frequently moving objects.
Ability to work in a fast-paced office setting, travel to other offices often, and use a computer constantly for eight hours.

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), maintain CCM status as directed by the governing agency and meet the appropriate continuing education criteria.

Responsibilities

Identify higher-risk patients with complex medical, behavioral, or psychosocial needs in collaboration with care team providers, and educate and assist them with care coordination.
Promote health literacy, patient involvement, and self-management by educating patients and collaborating with them about their health care needs and treatment options.
Collaborate with medical care team providers, patients, caregivers, and families to develop and implement care plans, and monitor adherence to individualized plans.
Manage a patient caseload according to acuity and follow-up needs.
Promote wellness through one-on-one education, identifying barriers to care, and assisting with lifestyle changes.
Build rapport with patients to improve engagement and self-care management.
Monitor emergency department and hospital discharge reports; coordinate post-discharge care and Transitional Care Management; assess discharge information, connect patients with healthcare professionals, and provide education and support regarding treatment plans and medication adherence.
Use clinical skills to prioritize and intervene to help maintain patient stability, and provide education and guidance on appointment scheduling based on health status and needs.
Continuously assess patient needs and individualized care plans through direct patient or representative contact and collaboration with provider staff; address gaps in care through outreach, education, and coordination.
Provide training and guidance to Care Management Coordinators in addressing individual patient needs.
Educate clinical staff about patient-specific issues and barriers to care, general health risk management, and population health issues.
Participate in patient care team meetings to support collaborative, patient-centered care and workflow processes.
Facilitate patient education programs addressing preventable conditions and existing chronic health problems, and identify patients who may benefit from those programs with provider care team members.
Work with the Director of Population Health to identify center-wide quality-of-care issues and improve work processes.
Perform other clinical duties and responsibilities assigned by the Director of Population Health.
Abide by the Corporate Compliance Manual's Code of Conduct, demonstrate commitment to Johnson Health Center and its mission, and treat patients and staff with dignity and respect.