RN Care Manager

Primary Health Solutions•Hamilton, OH

About The Position

This position is responsible for managing high risk, chronic condition patients to promote effective education, self-management support and timely healthcare delivery to achieve optimal quality and financial outcomes. Responsibilities include coordinating patient care to improve quality of care through the efficient use of resources and thereby enhancing quality, cost-effective outcomes. Acts as an advocate for the individual’s healthcare needs, and coordinates care to minimize the fragmentation of health care delivery systems. This position is committed to improving health status of the individual as well as the Primary Health Solutions community.

Requirements

RN required.
Proficiency in medication indications and side effects.
Understanding of medical tests and requirements for test as to provide the patients with appropriate information.
Minimum of 3 year of professional level medical experience; experience in care coordination preferred.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
Ability to write clear and concise routine reports and correspondence.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
Ability to interpret a variety of instructions furnished in written, oral, spreadsheet, diagram or schedule form.
To perform this job successfully, an individual should have the ability to gain knowledge of current practice management system, electronic medical record, Microsoft Word, Internet, and Intranet.
Must also be proficient in Microsoft Word, PowerPoint, and Excel.
Active Ohio RN license.
Excellent communications skills, both written and verbal.
Ability to work effectively with all levels of clinical and administrative staff within the health centers and with community providers.
Promotes collaborative teamwork.
Demonstrates program development and implementation skills.
Ability to represent the organization effectively in a variety of settings and with diverse communities.
Ability to work within a person-centered medical home model, work with disease management and participate in patient education.
Ability to work collaboratively with people of diverse cultures and lifestyles.
Excellent organizational skills and ability to handle multiple priorities while remaining calm and professional.
Ability to work independently with minimal supervision and be self-directed and flexible.
Ability to work at a high-volume level of accuracy.

Nice To Haves

Ability to speak Spanish desirable.

Responsibilities

Collaborates with providers and practice staff in identifying appropriate patients for care management, utilizing established Care Management criteria. Prioritizes patients according to intensity, need and required follow up.
Performs initial and periodic holistic assessments for care-managed population. The assessment includes a systematic and pertinent collection of data about the health status of the patient.
Formulates and implements a care management plan that addresses the patients identified needs by assessing the patient/family needs, issues, resources and care goals; determining the choices available to individual patients; educating the patient/family on the choices available. Establishes a care management plan that is mutually agreed upon by the health care team and the patient/family. Plans will contain specific mutual self-management goals, objectives, and interventions with the patients are action oriented. Identifies barriers and empowers patients/families to achieve maximum levels of wellness and self-management. Involves patient/family in the formation and ongoing evaluation of the plan of care.
Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, barriers/ issues and goals. Monitors and evaluates the progress of the patient.
Collaborates with the healthcare team to revise the care management plan when changes occur. Initiates discussions with multidisciplinary team regarding patient progress, new needs or problems, etc. Scans for gaps in care to identify patients needing the additional support of care management.
Identifies social determinants of health needs and effectively utilizes community resources to meet these needs.
Performs follow up calls for patients recently discharged from acute hospitalizations and who are considered high risk for readmission using establish criteria. Performs medication reconciliation for these care transitions.
Collaborates with providers, other healthcare team members (including inpatient facilities, the patient’s payer and health system administrators) to facilitate transitions of care across the healthcare continuum and optimize clinical and financial outcomes.
Maintains database on care managed population. Maintains accurate and timely documentation in the EMR.
Performs all duties and responsibilities in accordance with basic principles and guidelines of professional nursing. Participates in regular team meetings and appropriate quality and organizational committees. Participates in the orientation of new personnel. Abides by the organization’s compliance program and requirements. Works collaboratively with leadership team to improve and enhance care delivery through the evaluation, development and enhancement of policy and procedures.
Performs and/or participates in other appropriate projects or duties as assigned.