RN Care Manager Advanced Primary Care Lake County

University Hospitals•Concord, OH

About The Position

Under general supervision of the Supervisor, APC Care Management, the APC Administrator and the Ambulatory Site Clinical Lead provider (MD/DO, APRN, PA), perform as a member of the healthcare team to apply the nursing process when making nursing judgments and decisions specific to assessment, planning, implementation/delivery, and evaluation of patient care, and documenting relevant data and care processes. The RN Care Manager will facilitate communication between the patients and their Primary Care Providers. In addition, the RN Care Manager will assist with chronic disease action plans, transitional care management, Advance Directives planning, Annual Wellness Visits, and preventative care utilizing assessment skills both in person and telephonically. This RN position will be a resource for other team members and critical thinking skills are a must

Requirements

Graduate of an accredited school of nursing (Required) and
3+ years Clinical experience (Required) and
Experience working with Electronic Medical Record application and other computer based patient management tools (Required)
Excellent verbal and written communication skills (Required proficiency)
Proven skills in negotiation and collaboration (Required proficiency)
Proven time management and organizational skills (Required proficiency)
Demonstrated excellence in customer service (Required proficiency)
Demonstrated ability to apply concepts, utilize sound judgment and work independently. (Required proficiency)
Good computer skills and ability to utilize Microsoft Outlook, Excel, Word, and Power Point. (Required proficiency)
Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire)

Nice To Haves

Bachelor's Degree (Preferred)
1+ years In the outpatient, ED or urgent care setting (Preferred)
Knowledge in navigation of the health care system, including benefits coverage and health treatment protocols (Preferred proficiency)
CCM or ACM (Preferred)

Responsibilities

Exercise professional nursing judgment appropriate to the level of care needed, and prioritizing patient acuity and workload demands. The RN Care Manager will function with greater autonomy by consistently demonstrating independent clinical decision making abilities.
Provide patient care in a manner that demonstrates nursing knowledge and technical competence; recognize significant changes in patient’s condition/situation and take appropriate action. Communicate with patient/family including but not limited to relaying physician orders and changes in the plan of care, etc.
Assist and provide guidance to other staff members by acting as a nursing resource; appropriately delegate duties in accordance with appropriate rules/regulations and professional standards of nursing practice; promote team collaboration in meeting the needs of the patient/family.
Work as a leader in the Advanced Care Model in the ambulatory practice as assigned and work collaboratively with the APC Administrator and Director of APP & UHPS Nursing to drive system wide initiatives and changes
RN care management integrated into Primary Care office responsible for managing patient’s care across the continuum
Analyze sources of data to identify high risk patients and member groups
Manage high risk patients including patients with multiple comorbidities or high risk for readmission
Develop longitudinal care planning that includes assessment, planning, implementation and monitoring
Coordinate continuity of care with patients and families following hospital admission, discharge and ER visits
Advocate for patients by assisting in navigation of the health system
Communicate to the care team the patient’s goals and progress
Participate in quality improvement initiatives
Participate on data collection team to evaluate health outcomes, trends, utilization, cost reductions, and programmatic evaluation for areas of improvement
Provide 1 on 1 office visits for patients to implement care planning
Provide health and disease education to patients and families, including group education opportunities
Support patients in self-management of their disease and behavior modification interventions
As a member of the community care team, identifies appropriate resources including specialists, facilities, and external healthcare organization supports to provide an interdisciplinary approach
Collaborate with office staff in the coordination of individual patient care needs
Support and facilitate advanced care planning for patients and their families
Demonstrate proficiency and act as an expert role model in the performance of patient care
Performs other duties as assigned.
Complies with all policies and standards.
For specific duties and responsibilities, refer to documentation provided by the department during orientation.
Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.