RN, Care Manager

University of Rochester•Rochester, NY

About The Position

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive. This position manages clinical aspects of patient centered care including management of chronic conditions. This position works with the interdisciplinary medical team in the provision of patient care and development of program goals and initiatives.

Requirements

Bachelor's degree in Nursing or health related field and 3 years of relevant experience required
Or equivalent combination of education and experience
RN - Registered Nurse - State Licensure and/or Compact State Licensure upon hire required

Nice To Haves

Ambulatory care experience in community health, care management, disease management, quality improvement and/or management experience preferred

Responsibilities

Coordinates medical care of patients identified as high risk by health risk assessment/appraisal or by physician clinical determination.
Assumes coordination role at the point of service through targeted outreach and follow-up.
Assists in developing and implementing care plans for medically complex patients.
Identifies barriers to a successful care management path.
Identifies patient groups with chronic diseases.
Assists in developing and implementing population-based strategies to close gaps in medical care.
Identifies resources for patient self-management skills.
Coordinates use of clinical and ancillary resources within and outside of the health system to achieve treatment goals specified in the patient care plan.
Participates in program development by assisting with planning short-range and long-range program goals for chronic disease management.
Assists with the development of current evidence based protocols, policies, work flow/flow sheets, guidelines, etc. related to the provision of care within the medical home model.
Participates in committees as assigned.
Interacts effectively with physicians, home care team, patients, and their caregivers.
Accountable for patient triage.
Keeps abreast of organizational developments and practices that may impact operations by participating in continuing education courses, professional organizations and seminars, reading current literature and maintaining professional contacts in the community.
Other duties as assigned.