RN Care Manager - Griffin, GA Hybrid

Summit Health•Griffin, GA

4d•Hybrid

About The Position

As an RN Care Manager with VillageMD, you will collaborate with providers and engage high-risk patients to develop patient-centered care plans focused on chronic condition management and measured by clinical indicators. You will work with Care Coordinators, Nurse Navigators, Social Workers, providers, and other care team members to coordinate patient care while incorporating each patient's health and lifestyle goals. The role includes spending 2–3 days per week embedded in a physician office, working directly with providers and engaging high-risk patients. You will use clinical knowledge and understanding of community resources to provide health education, coordinate consultations and referrals, and support continuity of care. In the first year, you will build relationships with primary care practice teams, manage a caseload of high-risk patients, establish patient-specific goals, provide health interventions, and participate in grand rounds and meetings with provider partners and VillageMD leadership to discuss patient care and care-team processes.

Requirements

At least 3 years of direct clinical nursing experience.
Registered Nurse license in the state of practice.
Care management or transitional care management experience in a setting requiring assessment, critical thinking, and application.
Comfort with technology, including Microsoft suite of products.
Proficiency with electronic health records, including data capture, data mining, and reporting.
Valid driver's license and personal transportation for community visits.
Ability to be flexible in an ambiguous and dynamic environment.
Service orientation, a positive can-do attitude, and desire to work as part of a team.
Willingness to learn independently and take initiative.
Humility and ability to build trust through good communication and follow-through.
Confidence learning and using a variety of technology tools, applications, and systems.
Strong communication, time-management, and organizational skills.

Nice To Haves

Case Management Certification is preferred, but not required.

Responsibilities

Spend 2–3 days per week embedded in a physician office, working directly with providers and engaging high-risk patients.
Involve high-risk individuals in activities to improve their health and partner with the care team to establish goals and action steps focused on wellness, health management, and reducing unnecessary utilization.
Provide health education and coordinate consultations and referrals using clinical knowledge and community resources to support patients and continuity of care.
Develop relationships with primary care practice teams and operate as an extension of providers in supporting high-risk patients.
Engage a caseload of high-risk patients in Care Management, set patient-specific goals, and provide interventions to help them better manage their health.
Participate in grand rounds and meetings with provider partners and VillageMD leadership to discuss patient care and improvements to care-team processes.