Nurse Care Manager-RN

Patient First•Glen Allen, VA

1d•$35 - $49

About The Position

The Nurse Care Manager serves as a telephonic care management resource to clinical teams and actively manages an assigned panel of chronic care patients. The role partners with Patient First physicians, clinical leadership, the QIC Project Director, and other members of the care team to support quality improvement, identify and close gaps in care, and improve clinical practice effectiveness and efficiency. The Nurse Care Manager reviews patient records and reports, identifies patients who may benefit from care management, and supports patient health, wellness, safety, self-care, satisfaction, and cost-efficient care. The position assesses patients’ physical and psychosocial needs, coordinates care, develops and monitors individualized care plans, supports patient self-management, and communicates with patients and care teams about progress, recommendations, and follow-up. It also supports urgent and emergent calls within professional scope, coordinates with external providers and community resources, helps develop patient education resources, and may work as a center staff nurse as directed.

Requirements

Must be at least 18 years of age.
RN licensure required; must be able to obtain licensure in all states in which Patient First operates.
Current CPR, ACLS, and PALS certifications required.
Telephonic triage, coaching, or care coordination experience required.
Ability to work in a team-oriented environment, with strong organization and oral, written, presentation, and interpersonal communication skills.
Sound judgment and decision-making, problem-solving, and analytical skills.
Strong professional knowledge of comprehensive clinical assessment in the primary care population and chronic disease management.
Knowledge of psychosocial aspects of chronic illness.
Demonstrated success influencing patients and providers.
Experience with medically oriented care plan documentation and ability to develop and implement a plan of care.
Skills in active listening, critical thinking, social perceptiveness, active learning, and instruction methods for patient engagement and activation.
Comfort managing multiple tasks and continually reprioritizing.
Ability to delegate and exercise sound judgment while working with employees and providing medical care.
Ability to work effectively with all levels of administrative and professional personnel.
Ability to maintain confidentiality in accordance with organizational requirements and HIPAA.
Proficient computer skills, including Microsoft Word and Excel, presentation preparation, and database management.
Must be able to hear pages, bells, and the phone system.
Must be able to sit, stand, and walk for long periods, possibly 4 to 7 hours at a time.
Ability to travel, including overnight, to meetings and conferences as needed.
Ability to work extended hours, including nights and weekends, as needed.

Nice To Haves

BSN preferred.
Minimum of three years’ clinical experience in medical/surgical, ER, critical care, and ambulatory care preferred.
Case Manager certification or experience in case management and primary care/Patient-Centered Medical Home care, or an environment coordinating care across multiple providers, preferred.
Experience in quality improvement, quality and efficiency metrics, and data analytics preferred.
Bilingual ability is a plus.

Responsibilities

Serve as a telephonic care management resource to clinical teams and develop strong relationships with Patient First physicians to integrate care management into their practices.
Work with clinical leadership and the QIC Project Director to define quality measures, establish goals, and develop protocols and point-of-care reminders using nationally recognized, evidence-based care quality measures.
Help improve the effectiveness and efficiency of clinical practices and processes.
Review patient medical records and internal and external reports to identify and research possible gaps in care; work with clinical leadership on practice-level strategies to address and close those gaps.
Use available resources to identify patients appropriate for care management and actively manage an assigned panel of chronic care patients telephonically.
Assess patients’ physical and psychosocial needs, literacy status, and barriers affecting patients, families, and caregivers.
Educate patients and health care team members about preventive care and care coordination; support completion and documentation of health assessments required by individual payor contracts.
Work with patients and care teams to assess readiness for change and care needs, and develop individualized treatment care plans.
Monitor care plan effectiveness, modify plans as needed, provide clinical guidance, and help patients set SMART self-management goals.
Teach patients self-management tasks, report abnormal findings to the care team, and promote patient engagement in improving health.
Document self-management measures and mutually agreed care plans, and report progress toward goals.
Collaborate with patients, families, caregivers, physicians, and other care team members to assess progress toward health care goals.
Coordinate referrals, hospitalizations, ER visits, ancillary testing, medication reconciliation, and other aspects of patient care.
Communicate with patients about compliance with recommendations and follow-up visits; review documentation from other providers, follow up as needed, and document conversations and recommendations in the electronic medical record as appropriate.
Follow Patient First protocols when handling urgent and emergent calls, and assist center nurses and other health care team members with advice and calls within the Nurse Care Manager’s professional scope.
Anticipate chronic care patients’ needs and review necessary documentation and pre-visit planning with patients when possible.
Instruct and encourage patients to use the Patient First patient portal, and facilitate communication between patients and care team members in decision-making.
Use motivational interviewing to assess barriers to treatment goals and help patients address issues and remove barriers to care.
Oversee development, procurement, and adoption of patient self-management education resources for primary clinical teams.
Collaborate with external case managers and develop a list of medical supply and community resources; maintain collegial relationships with frequently used organizations.
Work with consulting physicians, hospitals, ERs, and other health care resources to clarify roles and develop effective communication.
Facilitate, advocate, and intervene on behalf of patients to support implementation of treatment care plans and continuity of care.
Work as a center staff nurse as directed.

Benefits

Health, dental, and vision insurance for employees and dependents.
Disability, life, and long-term care insurance.
Employee Assistance Program.
Flexible Spending accounts.
401(k) Retirement Plan with employer match.
Paid Annual Leave.
Volunteer Time Off Pay.
Bereavement Leave.
Emergency Leave Bank.
Overtime Pay.
Holiday Pay and double-time compensation for holidays worked.
Discounted medical treatment at Patient First locations for employees and immediate family.
Recruitment bonus.