RN, Chronic Disease Case Manager
About The Position
The RN, Chronic Disease Case Manager supports patients’ wellness, prevention, chronic disease self-management, care transitions, and access to resources. The role collaborates with patients, caregivers, families, providers, and other members of the primary care team to address patient needs and improve quality of care and health outcomes. The position reviews registries, quality measures, and value-based contract metrics to help the primary care team meet quality goals and benchmarks. It helps patients navigate the health care system and understand their treatment, introduces patients to available care management and monitoring programs, addresses social determinants of health needs, and promotes health equity. The case manager also provides health coaching, supports patient-centered goal setting and care planning, recognizes changes in patient condition, and reports those changes to a medical provider. Other duties may be assigned.
Responsibilities
- Collaborate with the health care team to support wellness, wellness exams, and healthy living habits.
- Review registry information to identify and assist with patient needs and quality of care.
- Review quality measures and assist providers and the primary care team in meeting and exceeding 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 to achieve quality goals.
- Guide patients through the health care system and transitions involving primary care, specialists, and ancillary departments, ensuring they understand their 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 members 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 pursuing 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 and recognize abnormal symptoms or changes in patient condition and appropriately report condition changes to a medical provider.
- Encourage habits conducive to a higher quality of life.
- Use motivational interviewing to assist patients in reaching 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
