Registered Nurse/Care Manager

Sun River Health•Poughkeepsie, NY

1d•Onsite

About The Position

Sun River Health is currently seeking a full-time Registered Nurse/Care Manager to join our team at our Poughkeepsie - Washington Street site. The RN Care Manager is responsible for coordinating screenings, assessments, care planning, and providing care management services to patients identified as having complex chronic care needs. Acts as a connector between patient needs and the resources provided by the care management program. The RN care manager will promote self-care management and assist with access to care. The RN care manager works with patients through direct face to face patient contact or telephonically. Provides guidance and leadership in the care management program to those in the healthcare organization as well as ensuring the patients receive the best possible care.

Requirements

Bachelor of Science Nursing (BSN)
NYS RN Licensed and CPR/Infection Control Certification

Nice To Haves

Bilingual Spanish speaking preferred
2-4 years Preferred Work-Related Experience

Responsibilities

Identifies, tracks and manages care for designated risk stratified patients
Conducts initial care coordination screening eligibility and performs comprehensive risk assessment
Works directly with patients/family members and providers to develop and implement an individualized and integrated patient care plan for patient
Promotes clear communication amongst a care team including treating clinicians by ensuring awareness regarding patient care plans
Adapts practice to meet individual patient circumstances considering level of health literacy and cultural and linguistic differences, ensuring that effective communication is achieved, particularly where there may be barriers to understanding
Ongoing clinical assessment, monitoring and follow up for designated risk stratified patients
Assessment and early identification of decompensating disease with appropriate intervention and management
Assesses psychological needs and ability to benefit from community resources and referrals to outside agencies/programs when appropriate
Performs medication review, reconciliation and coordination with a licensed prescriber for medication adjustment where indicated
Provides organizational approved patient education materials including but not limited to health promotion and disease management
Assists in the maintenance of the patient’s health, wellness and prevention of secondary disease complications by providing education, counseling and support
Handles protective health information in a manner consistent with the Health Insurance Portability and Accountability Act (HIPAA)
Collaborates with interdisciplinary teams to assess patient needs and deliver care to identified population upon discharge from varying clinical settings.
Supports care transitions by coordination of activities needed to prevent or reduce utilization of emergency services or hospitalizations
Ensures the ongoing and timely reassessment and follow-up of all care plans on a scheduled basis ensuring timely updating and documentation of patient progress toward agreed upon goals
Promotes the coordination of relevant health and social care services to remove barriers related to social determinants of health