About the position
ArchWell Health is re-imagining the practice of primary care. We are putting the relationship between patient and physician at the center of a value-based model focused on outstanding patient experience, improved access, and better outcomes. In our medical clinics, we provide comprehensive primary care for senior adults with traditional Medicare and Medicare Advantage plans, focused on delivering improved quality, better patient experience and lower total cost of care. The Nurse Care Manager is responsible for helping coordinate and evaluate the management of patients with acute and chronic conditions, across the care continuum, to achieve high quality care measured by positive patient outcomes. This position will work closely with members of the care team to follow the patient from our centers into acute and post-acute facilities, as well as their home environments. The Nurse Care Manager plays a pivotal role in developing the care plan alongside the care team and then executing to achieve goals/objectives, standards of performance, regulatory compliance, and quality patient care.
Responsibilities
- Establish a trusting relationship with patients, their families, and/or caregivers.
- Collaborate with clinical staff and other care team members to achieve patient goals.
- Reduce network costs by driving referrals to preferred groups and identifying excessive referral requests.
- Identify high-risk/complex patients.
- Assess physical, functional, social, psychosocial, environmental, learning, and financial needs and develop a comprehensive, individualized care plan based upon identified needs.
- Perform case management following the nursing process and standards of practice established by the Case Management Society of America (CMSA).
- Provide patient education, care coordination, and other interventions needed to help patients achieve their health goals.
- Utilize Motivational Interviewing to build patient engagement.
- Evaluate progress toward patient's goal achievement.
- Communicate telephonically with hospital case managers, physical therapists (PT), social workers, patients, and families/caregivers to facilitate a safe discharge plan.
- Manage and plan for transitions of care.
- Conduct transitions of care assessment/screening, medication reconciliation, and care coordination following discharge to home.
Requirements
- Ability to plan, implement and evaluate patient specific care plans.
- Experience with monitoring, assessing, recording, and adjusting plan accordingly.
- Working knowledge of patient medical records.
- Working knowledge of community-based organizations and social services support agencies/network.
- Strong interpersonal communication skills with exceptional active listening abilities.
- Highly empathetic, non-judgmental, and open-minded.
- Experience in a collaborative team environment.
- Self-starter, critical thinker, and owner.
- Demonstrated ability to work independently in a remote setting.
- Associate degree in Nursing required.
- A valid, active, unrestricted Registered Nurse (RN) license in State of employment required.
- A minimum of 2 years' clinical work experience required.
- A minimum of 1 year of utilization review, home health, discharge planning experience highly desired.
- A minimum of 1 year of case management experience in acute case management or ambulatory case management experience highly desired.
- Proficient computer skills including Microsoft Office.
Nice-to-haves
- Bachelor's Degree in Nursing (BSN) or RN with bachelor's degree in a related clinical field preferred.
- Certified Case Manager certification is preferred.
- ICD-10, CPT codes, HCPCS knowledge preferred.
- Managed care experience including knowledge of HEDIS and CMS guidelines preferred.
- Fluency in Spanish or other languages spoken by people in the communities we serve (where necessary).
Benefits
- Equal opportunity employer.
