RN Care Manager - FGC

ArchWell Health•Tampa, FL

17d

About The Position

ArchWell Health is re-imagining primary care by placing the relationship between patient and physician at the center of a value-based model focused on patient experience, access, and outcomes. Its clinics provide comprehensive primary care for senior adults with traditional Medicare and Medicare Advantage plans. The Nurse Care Manager coordinates and evaluates management of patients with acute and chronic conditions across the care continuum to support high-quality care and positive patient outcomes. The role works closely with the care team to follow patients from ArchWell Health centers into acute and post-acute facilities and home environments. The Nurse Care Manager helps develop individualized care plans with the care team and executes them in accordance with goals, performance standards, regulatory requirements, and quality-care expectations.

Requirements

Associate degree in Nursing.
Valid, active, unrestricted Registered Nurse (RN) license in the state of employment.
Willingness to obtain RN licensure in other states where ArchWell Health has centers, including compact and non-compact locations.
At least 2 years of clinical work experience.
Ability to plan, implement, and evaluate patient-specific care plans.
Experience monitoring, assessing, recording, and adjusting care plans as appropriate.
Working knowledge of patient medical records.
Working knowledge of community-based organizations and social-services support agencies or networks.
Strong interpersonal communication skills and exceptional active-listening abilities.
Empathetic, non-judgmental, and open-minded approach.
Experience working in a collaborative team environment.
Self-starter with critical-thinking skills and ownership.
Ability to work independently in a remote setting.
Proficient computer skills, including Microsoft Office.
Commitment to ArchWell Health’s mission and values.

Nice To Haves

Bachelor’s degree in Nursing (BSN) or an RN license with a bachelor’s degree in a related clinical field.
At least 1 year of utilization review, home health, or discharge-planning experience.
At least 1 year of acute or ambulatory case-management experience.
Certified Case Manager certification.
Certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN), or willingness to obtain certification within a specified time.
Knowledge of ICD-10, CPT codes, and HCPCS.
Managed-care experience, including knowledge of HEDIS and CMS guidelines.
Fluency in Spanish or other languages spoken by people in the communities served, where necessary.

Responsibilities

Build trusting relationships with patients, families, and caregivers.
Collaborate with clinical staff and other care team members to achieve patient goals.
Reduce network costs by directing referrals to preferred groups and identifying excessive referral requests.
Identify high-risk and complex patients.
Assess physical, functional, social, psychosocial, environmental, learning, and financial needs and develop individualized care plans.
Perform case management according to the nursing process and standards of practice established by the Case Management Society of America (CMSA).
Provide patient education, care coordination, and other interventions to help patients achieve their health goals.
Use Motivational Interviewing to build patient engagement.
Evaluate progress toward patient goals.
Communicate by telephone with hospital case managers, physical therapists, social workers, patients, and families or caregivers to facilitate safe discharge plans.
Manage and plan transitions of care.
Conduct transitions-of-care assessments or screenings, medication reconciliation, and care coordination following discharge to home.