The Registered Nurse (RN) Care Manager will facilitate communication among patients/families, multidisciplinary teams, medical management teams, and community resources to identify and resolve barriers to care delivery. This role involves interpreting contracts to achieve optimal clinical and financial outcomes. The nurse will collaborate with patients, families, and inter-professional teams to ensure quality, efficient, and cost-effective healthcare services, potentially working embedded in a provider office or telephonically. The position utilizes evidence-based approaches to increase patient and family activation and engagement, partnering with them to develop SMART goals and assisting in the adoption of self-management educational resources. The RN will identify learning barriers and report abnormal findings to the care team, collaborating on a plan. They will independently manage their caseload, ensuring timely completion of tasks and documentation related to MCO, regulatory, and contractual requirements. The role involves partnering with at-risk patients throughout their care journey to ensure continuity, anticipating needs, responding to changes in status, and prioritizing care based on essential patient needs. Coordination of patient information and communication between various entities, including referring/accepting facilities and physicians, community caregivers, and other members of ACM, is crucial for smooth transitions of care. Referrals to internal and external resources will also be coordinated. The nurse must demonstrate knowledge and skills appropriate for the age of the patients served, understanding principles of growth and development, and assessing patient status to meet age-specific needs.
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Job Type
Full-time
Career Level
Mid Level