RN, Chronic Disease Case Manager
About The Position
The RN, Chronic Disease Case Manager collaborates with patients, caregivers, families, providers, and the primary care team to support wellness, prevention, chronic disease self-management, care transitions, and quality goals. The role uses patient education, navigation, resource coordination, health coaching, and patient-centered care planning to help patients meet their needs and improve quality of life. The case manager reviews patient registry information and quality and value-based contract measures, supports workflows and efforts to meet or exceed benchmarks, and assists patients as they move among primary care, specialists, and ancillary departments. The role also helps patients access care-management and remote-monitoring programs, addresses social determinants of health needs, and promotes health equity. Other duties may be assigned.
Responsibilities
- Collaborate with the health care team to support wellness, including wellness exams and healthy living habits.
- Review registry information to identify and assist with patient needs and quality of care.
- Review quality measures and help providers and the primary care team meet or exceed metric benchmarks.
- Educate patients about wellness and prevention to support quality of life.
- Review value-based contract metrics and help the primary care team implement workflows that support patient quality goals.
- Guide patients through the health care system and transitions among primary care, specialists, and ancillary departments, supporting their understanding of treatment.
- Introduce patients to transitional care management (TCM), chronic care management (CCM), principal care management (PCM), and remote patient monitoring (RPM) programs to support chronic disease and comorbidity self-management.
- Collaborate with the primary care team, patients, caregivers, and family to ensure patient needs are met at the point of care.
- Assist patients with social determinants of health (SDoH) needs and resource allocation.
- Lead the primary care team in efforts to achieve health equity for patients seen in primary care.
- Communicate and collaborate effectively with health team members.
- Educate patients about chronic diseases and comorbidities and assist with self-management.
- Identify abnormal symptoms or changes in a patient's condition and report condition changes appropriately to a medical provider.
- Encourage habits that support a higher quality of life.
- Use motivational interviewing to help patients reach health care goals.
- Collaborate with patients to develop patient-centered plans.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
