RN Rare and Chronic Disease Manager

Amery Hospital & Clinic•Bloomington, MN

20h•$35 - $53

About The Position

The RN Rare and Chronic Disease Manager provides telephone-based services for individuals in chronic disease management programs, including outreach, evaluation, engagement, education, counseling, self-management support, and care integration. The role implements performance improvement strategies based on reviews of patient and program outcomes and provides dependable support to patients and the disease management team. The manager facilitates communication among patients, health care providers, and community resources, and coordinates support from health professionals and family members across the care continuum. The position delivers individualized, patient-focused support to help people reach health-related goals and achieve optimal care. It integrates clinical, functional, and health behavior information into action-oriented care plans; coordinates with case managers and other providers as needed; and supports communication and collaboration among patients, families, providers, and community services. The role also maintains documentation and outcome tracking, uses automated systems and chronic disease care guidelines, contributes to quality improvement and departmental work, and maintains professional knowledge, licensure, and certifications as applicable.

Requirements

Current, unrestricted Registered Nurse license in Minnesota, with no history of restrictions or sanctions within the last 10 years.
Three years of clinical practice experience with current clinical knowledge related to chronic disease management.
Health behavior change coaching experience.
Experience collaborating effectively and problem-solving with patients and health care team members.
Strong written and verbal communication skills, including the ability to communicate with individuals at all organizational levels.
Demonstrated working knowledge of quality improvement and understanding of health care.
Experience using and managing automated medical management systems.
Ability to engage patients with various dispositions in programs.

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred.
Experience assessing, educating, and providing disease self-management support to members or patients by telephone.

Responsibilities

Provide telephone-based outreach, evaluation, engagement, education, counseling, self-management support, and care integration for chronic disease management program participants.
Individualize services to each patient’s needs and identify interventions and resources that help patients achieve their health-related goals.
Identify patient patterns and improvement strategies to support better health and optimal care outcomes.
Refer patients to and co-manage services with Complex Case Management and Inpatient Case Managers when a higher level of management is needed.
Engage patients referred to disease management programs and refer them to care providers or other resources as appropriate.
Integrate clinical, functional, and health behavior information into action-oriented, time-specific plans and interventions.
Facilitate communication and integration among patients, families, providers, care programs, and community-based services.
Communicate routinely with patients and families to improve understanding of health and support successful outcomes.
Collaborate with primary care and specialty providers to support optimal patient health outcomes.
Provide chronic illness education and self-management support.
Maintain accurate documentation of disease management activities and assist with tracking database outcomes.
Maintain confidentiality in accordance with department and corporate policies.
Build and maintain working relationships with department colleagues, other HealthPartners departments, and health care team participants to coordinate patient care.
Participate in appropriate departmental and organizational meetings and work cooperatively with leadership in support of departmental goals.
Use automated applications and systems effectively, maintain knowledge of chronic disease guidelines and standards of care, and seek training when needed.
Participate in ongoing professional education related to health behavior change and chronic disease management; maintain current licensure and certifications as applicable.
Participate in committees, task forces, projects, and quality improvement teams as assigned, and perform other assigned duties.
Implement performance improvement strategies identified through review of patient and program outcomes.