Nurse Care Manager

Brown Health Medical Group•East Providence, RI

11d•Onsite

About The Position

The Nurse Care Manager works on an interdisciplinary healthcare team in a specialty care setting, providing direct patient care and participating in quality improvement activities. The role is part of a program implementing strategies to meet specified quality measures and is responsible for comprehensive screenings, assessments, care coordination, disease education, and self-management support for patients with chronic kidney disease and other chronic conditions. The Nurse Care Manager is integrated into an office-based healthcare team and works with patients, primary care providers, dialysis centers, and other stakeholders to promote patient-centered care. Key areas include education about kidney replacement therapy, transplantation, palliative care, and hospice; preparation for the patient’s chosen treatment modality; and efforts to prevent hospitalizations among dialysis patients and patients at risk for rapid progression of advanced kidney disease. Care is provided in person and via telehealth. The position 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. The role is scheduled for 30 hours per week, with variable weekdays and hours between 8:00 a.m. and 5:30 p.m. The position is based in East Providence, Rhode Island, and does not require driving.

Requirements

Current license to practice as a Registered Nurse in Rhode Island.
Current AHA Basic Life Support (BLS) certification.
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.
Ability to work independently and collaboratively to achieve goals.
Strong organization and attention to detail.
Sound judgment and decision-making ability, including the ability to assess and differentiate priorities.
Excellent interpersonal skills and ability to work with and through others.
Excellent written and verbal communication skills.
Ability to maintain confidentiality in accordance with practice policy and state and federal regulations, exercising discretion with sensitive information.
Computer proficiency, including Microsoft Word, Excel, Access, and web-based applications.
Knowledge and skills to provide care with consideration of aging processes, human development stages, and cultural patterns.

Nice To Haves

Baccalaureate in Nursing (BSN).
Experience working with chronic kidney disease or dialysis patients on care coordination, disease management, or education.
Certified diabetes outpatient education (CDOE/CVDOE) credential, or willingness to obtain it within two years of hiring.

Responsibilities

Collaborate with the care team to identify and case-manage patients at high risk of adverse health outcomes, maintaining communication with providers and office staff about patient status.
Implement patient-centered care and evidence-based healthcare, applying knowledge of healthcare delivery access points and services.
Coordinate communication among patients, providers, and stakeholders to implement action plans and improve health 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.
Educate patients about their chronic illnesses, including pathology, signs and symptoms, complications, and medications.
Conduct or review medication reconciliations and work with providers or team pharmacists to support medication management and adherence.
Develop care plans, interventions, and treatment goals with patients, and review them with providers and clinical team members.
Address barriers to patient health and advocate for access to timely services across the continuum of care.
Support safe, effective, and efficient transitions home from the Emergency Department and provide timely telephone follow-up for complex patients presenting 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, identify and use cultural and community resources, and facilitate access to culturally and linguistically appropriate services as needed.
Use an interdisciplinary team approach to plan and coordinate care and support other team members in assisting patients with their treatment plans.
Use the Electronic Medical Record, chronic disease registry, and other reporting tools to prioritize patient follow-up.
Generate quarterly reports on service volume, patient distribution by plan, and services provided; analyze data and implement performance improvement strategies.
Maintain knowledge of professional nursing practice within the legal framework of the Rhode Island Nurse Practice Act and attend training or retraining as needed.
Share best practices, serve as a medical home advocate and advisor, lead by example, and encourage a positive work environment.
Participate with the interdisciplinary team in establishing protocols, risk management activities, performance improvement initiatives, and quality measures.
Maintain safety, environmental, and infection-control practices in accordance with organizational policies, procedures, and objectives, and maintain a safe environment for patients, visitors, and staff.
Perform other related duties as assigned.