Nurse Care Manager

Brown Medicine•East Providence, RI

4d•$74,256 - $148,512•Onsite

About The Position

The Nurse Care Manager reports to the Director of Quality Programs for the Division of Kidney Disease and Hypertension and works under the general supervision of that Director, the Practice Physician Medical Director, and departmental policies. As part of an interdisciplinary healthcare team in a specialty care setting, the Nurse Care Manager provides direct patient care and participates in quality improvement activities for a program implementing strategies to meet specified quality measures. The role provides comprehensive screenings, assessments, care coordination, disease education, and self-management support for patients with chronic kidney disease and other chronic conditions. Integrated into an office-based healthcare team, the Nurse Care Manager promotes patient-centered care and frequent communication with primary care providers and dialysis centers. The role educates patients about kidney replacement therapy, transplantation, palliative care, hospice, and preparation for their chosen modality. It also focuses on preventing hospitalizations among dialysis patients and patients at risk for rapid progression of advanced kidney disease. Care is delivered in person and via telehealth.

Requirements

Current license to practice as a Registered Nurse in Rhode Island.
Current AHA Basic Life Support (BLS) certification.
Receipt of certified diabetes outpatient education (CDOE/CVDOE) certification or willingness to obtain it within two years of hiring.
Minimum of three years of experience in a community health setting, public health, chronic disease management, community nursing, or case management is preferred.
Experience working with primary care providers to coordinate care and disease management.
Knowledge and skills to care for patients with consideration of aging processes, human development stages, and cultural patterns.
Ability to work independently and collaboratively to achieve goals.
Strong organizational skills and attention to detail.
Sound judgment and decision-making skills, including the ability to assess and differentiate priorities.
Excellent interpersonal skills and ability to work effectively with others.
Excellent written and verbal communication skills.
Ability to maintain confidentiality of information, including patient data, in accordance with practice policies and state and federal regulations.
Computer proficiency, including Microsoft Word, Excel, Access, and web-based applications.

Nice To Haves

Baccalaureate in Nursing (BSN) preferred.
Experience in community health, public health, chronic disease management, community nursing, or case management.
Experience coordinating care and disease management or education for chronic kidney disease and dialysis patients.

Responsibilities

Collaborate with the care team to identify and case-manage patients at high risk of adverse health outcomes, communicating patient status with providers and office staff.
Establish and implement patient-centered care and administer evidence-based healthcare.
Coordinate communication among members, providers, and stakeholders to implement action plans that improve patients’ overall health and outcomes.
Provide screenings, assessments, care coordination, disease education, and self-management support for patients with chronic conditions, particularly chronic kidney disease, hypertension, diabetes, and depression, in the office or home as needed.
Educate patients about their chronic illnesses, including pathology, signs and symptoms, complications, and medications used in treatment.
Conduct or review medication reconciliation and work with providers or team pharmacists on medication management and adherence.
Work individually with patients to develop plans of care, interventions, and treatment goals, and review them with providers and clinical team members.
Address barriers to optimal health and advocate for patient access and timely services across the continuum of care.
Support safe and efficient transitions home from the Emergency Department and provide timely telephone follow-up for complex patients who present to the ED.
Use behavior-change techniques, including motivational interviewing, to help patients establish self-management goals and action plans with timeframes.
Coordinate care and outreach as a liaison, identifying and using cultural and community resources and arranging culturally and linguistically appropriate services as needed.
Use an interdisciplinary team approach to coordinate care and support team members in carrying out patients’ treatment plans.
Use the Electronic Medical Record, chronic disease registry, and other reporting tools to prioritize follow-up.
Generate quarterly service reports, analyze data, and develop and implement performance-improvement strategies to meet and exceed quality expectations.
Maintain knowledge of professional nursing practice within the legal framework of the Rhode Island Nurse Practice Act.
Attend training and retraining as needed to maintain current knowledge of patient care practices and procedures.
Share best practices, serve as a medical-home advocate and advisor, and support a positive work environment.
Participate in establishing protocols, risk-management activities, performance-improvement initiatives, and quality measures with the interdisciplinary team.
Maintain safety, environmental, and infection-control practices in accordance with organizational policies, procedures, and objectives, and help maintain a safe environment for patients, visitors, and staff.
Perform other related duties as assigned.