Nurse Care Manager

Patient First•Glen Allen, VA

6d•$35 - $49•Remote

About The Position

The Nurse Care Manager serves as a telephonic care management resource to clinical teams, integrating the care management program into practices, defining quality measures, and improving clinical practices. This role involves reviewing patient records to identify gaps in care, managing a panel of chronic care patients telephonically, and maximizing patient health, wellness, safety, and self-care through quality care management, patient satisfaction, and cost-efficiency. The Nurse Care Manager also assists center nurses and other healthcare team members by providing advice and handling emergent or urgent calls within their scope of practice.

Requirements

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

Nice To Haves

RN, BSN preferred
Minimum of three years’ clinical experience in medical/surgical, ER, critical care, and ambulatory care preferred
Certification as a Case Manager or experience in Case Management and Primary Care/Patient-Centered Medical Home Care or environment that coordinates care across multiple providers preferred
Experience in quality improvement, quality and efficiency metrics, and data analytics preferred
Bilingual a plus

Responsibilities

Serving as a telephonic care management resource to clinical teams
Developing and maintaining strong relationships with Patient First Physicians to integrate the care management program into their practices
Working 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 (EBC) quality measures
Working with clinical leadership and the QIC Project Director to improve the effectiveness and efficiencies of clinical practices and processes
Reviewing patient medical records and both internal and external reports to identify and research possible gaps in care
Working with clinical leadership to identify strategies to address and close identified gaps in care at the practice level
Using the resources available to actively and efficiently identify patients appropriate for care management
Maximizing the patients’ health, wellness, safety, and self-care through quality care management, patient satisfaction, and cost-efficiency
Assisting center nurses and other members of the health care team by providing advice and handling emergent or urgent calls that are within the Nurse Care Manager’s scope of professional practice
Actively managing assigned panel of chronic care patients telephonically
Developing relationships with patients as an integral member of the health care team
Assessing patients’ physical and psychosocial needs, including establishing literacy status and identifying barriers of the patient, family, and caregivers
Educating patients and health care team members on the importance of preventative care and care coordination
Supporting efforts to help ensure that a complete health assessment is performed and on file for each identified primary care patient to meet individual payor contractual requirements
Working with patients and the patients’ care teams to coordinate change readiness and needs assessment and to develop individualized treatment care plans
Monitoring and evaluating effectiveness of the treatment care plan and modifying as necessary
Providing expert clinical guidance resulting in transformational changes in the patients’ overall wellbeing
Assisting patients in setting specific, measurable, achievable, relevant, and time-based (SMART) goals for self-management
Teaching patients how to conduct self-management tasks; reporting abnormal findings to the care team
Promoting patient engagement and self-management by involving the patient in activities to improve his or her health
Documenting patient self-management measures, creating a mutually agreed upon care plan, and reporting progress towards identified goals
Collaborating with patients, family members, caregivers, Physicians, and other care team members to assess the patients’ progress toward identified health care goals
Managing various aspects of patient care (e.g., referrals to specialists, hospitalizations, emergency room (ER) visits, ancillary testing, and medication reconciliation) and assisting the patient in coordination of care
Communicating with patients to ensure compliance with recommendations and follow-up visits
Reviewing documentation from other providers (e.g., hospital discharge summaries), following up with the patient as necessary, and documenting conversations with and recommendations made to the patient in the electronic medical record as appropriate
Following Patient First protocols when handling urgent and emergent calls
Anticipating the needs of the chronic care patient population and ensuring that necessary documentation and pre-visit planning is reviewed with the patient when possible
Instructing and encouraging patients on use of the Patient First patient portal
Facilitating communication between members of the health care team and patients in the decision-making process
Assessing patient barriers to complete treatment goals through motivational interviewing and assisting the patient in mitigating issues and removing barriers to care
Overseeing the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams
Collaborating with external case managers for additional services as appropriate
Developing a list of medical supply and community resources available to patients, and maintaining collegial relationships with frequently used organizations
Working with consulting Physicians, hospitals, ERs, and other frequently used health care resources to clarify roles and develop effective and efficient communication
Facilitating, advocating, and intervening on behalf of the patient to ensure successful implementation of the treatment care plan and continuity of care
Working 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
Double time compensation for all holidays worked
Discounted medical treatment at any Patient First location for employees and immediate family
Recruitment Bonus