RN Care Manager - Griffin, GA Hybrid

Summit Health CityMD•Griffin, GA

3d•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, and other team members to coordinate collaborative care while incorporating patients’ personal health and lifestyle goals. The role includes spending two to three days per week embedded in a physician office, working directly with providers and engaging high-risk patients. You will help patients improve their health, establish patient-specific goals and action steps, and support wellness, better health management, and reduced unnecessary utilization. Using clinical knowledge and an understanding of community resources, you will provide health education and coordinate consultations and referrals to support continuity of care. During the first year, you will build relationships with primary care practice teams, manage a caseload of high-risk patients, provide interventions to help patients manage their health, 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 with licensure 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 using a variety of electronic health records, including data capture, data mining, and reporting.
Valid driver’s license and personal transportation for community visits.
Flexibility in an ambiguous and dynamic environment.
Service orientation, positive attitude, and desire to work as part of a team.
Willingness to learn independently and take initiative.
Humility and ability to gain 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.

Responsibilities

Collaborate with providers to develop patient-centered care plans for high-risk patients, focusing on chronic condition management and clinical indicators.
Spend two to three days per week embedded in a physician office, working directly with providers and engaging high-risk patients.
Partner with patients and the care team to establish goals and action steps that support wellness, improved health management, and reduced unnecessary utilization.
Provide health education and coordinate consultations and referrals using clinical knowledge and community resources.
Build relationships with primary care practice teams and support high-risk patients as an extension of the provider.
Manage a caseload of high-risk patients, set patient-specific goals, and provide interventions to help patients better manage their health.
Participate in grand rounds and meetings with provider partners and VillageMD leadership to discuss patient care and care-team process improvements.