RN Care Manager - FGC

ArchWell Health•Tampa, FL

18d

About The Position

ArchWell Health is re-imagining primary care by centering the relationship between patient and physician in a value-based model focused on outstanding patient experience, improved access, and better outcomes. Its clinics provide comprehensive primary care for senior adults with traditional Medicare and Medicare Advantage plans, with a focus on improved quality, better patient experience, and lower total cost of care. The Nurse Care Manager helps coordinate and evaluate the management of patients with acute and chronic conditions across the care continuum to achieve high-quality care and positive patient outcomes. The position works closely with care team members to follow patients from ArchWell Health centers into acute and post-acute facilities and their home environments. The Nurse Care Manager develops care plans alongside the care team and executes them to achieve patient goals and objectives, standards of performance, regulatory compliance, and quality patient care.

Requirements

Associate degree in Nursing.
Valid, active, unrestricted Registered Nurse (RN) license in the state of employment.
Willingness to obtain an RN license in other states where ArchWell Health has a center, 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, and recording patient information and adjusting plans accordingly.
Working knowledge of patient medical records.
Working knowledge of community-based organizations and social services support agencies and networks.
Strong interpersonal communication skills and exceptional active listening abilities.
Highly empathetic, non-judgmental, and open-minded approach.
Experience working in a collaborative team environment.
Self-starter, critical thinker, and owner.
Demonstrated ability to work independently in a remote setting.
Mission-driven and motivated to join an organization transforming accessible, clinically excellent care for seniors.
Proficient computer skills, including Microsoft Office.
Fluency in Spanish or other languages spoken by people in the communities served, where necessary.
Embodies and serves as a role model of ArchWell Health’s values: be compassionate, strive for excellence, earn trust, show respect, stay resilient, and always do the right thing.

Nice To Haves

Bachelor’s degree in Nursing (BSN) or RN 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 case management experience in acute or ambulatory case management.
Certified Case Manager 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.

Responsibilities

Establish a trusting relationship with patients, their families, and/or caregivers.
Collaborate with clinical staff and other care team members to achieve patient goals.
Reduce network costs by driving referrals to preferred groups and identifying excessive referral requests.
Identify high-risk and complex patients.
Assess patients’ physical, functional, social, psychosocial, environmental, learning, and financial needs, and develop comprehensive, individualized care plans based on identified needs.
Perform case management following 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 patients’ goal achievement.
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 and screenings, medication reconciliation, and care coordination following discharge to home.