Outpatient Registered Nurse Care Manager, Per Diem

St Luke's University Health Network•Allentown, PA

62d

About The Position

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. The Outpatient Care Manager is responsible for assisting the care team (providers, medical assistants, nurses, and additional clinical personnel.) by coordinating care for patients on providers' daily schedules, and by proactively managing and coordinating care for patients not on the schedule so as to offer complete preventive and/or chronic care for all St. Luke's Physician Group patients.

Requirements

RN degree and license for the appropriate state (PA & NJ,) required.
3+ years of direct patient care experience.
Current CPR or equivalent
Proficient in Excel and Word.

Responsibilities

Responsible for pre-visit planning; reviews provider schedules and individual patient charts in order to assist the care team to coordinate care for visits and future healthcare needs.
Monitors and/or schedules follow-up primary care visits within 48 hours of ED visit, urgent care appointment, or hospital discharge.
Responsible for working with patient and patient's care team to develop an individualized treatment care plan - including follow-up appointments, labs and other care coordination.
Tracks follow-up visits with appropriate specialists for complex patients.
Communicates with and coaches patients to ensure that they are aware of discharge instructions; have necessary prescriptions; have access to medications and understand how to take the necessary medications, including what to look for regarding adverse events as per their care givers' instructions.
Facilitates the information flow between hospitals, long-term care facilities, home health representatives, and the patient' s primary care team.
Works with providers, clinical staff members, and clerical staff members to help identify high risk, high need patients.
Assists physicians and other care team members in implementing processes for best practices in preventive services, chronic care and disease management.
Utilizes electronic health record, chronic disease registry, and other quality reporting software to capably manage the care of individual patients and populations.
Works collaboratively with providers and the care team to ensure patient adherence to medical plan of care, including all appropriate preventive and disease-specific screenings, interventions, and treatment goals - including self-management goals.
Identifies, utilizes, and properly directs patients to cultural and community resources. Verifies that practices have necessary behavioral health screening tools.