Nurse Care Manager

About this role

The responsibilities of this job include, but are not limited to, the following: • Serving as a telephonic care management resource to clinical teams, including: • Developing and maintaining strong relationships with Patient First Physicians to integrate the care management program into their practices; • Working with clinical leadership and the QIC Project Director to define quality measures, establish goals, and develop protocols and point of care reminders using nationally recognized, evidence-based care (EBC) quality measures; • Working with clinical leadership and the QIC Project Director to improve the effectiveness and efficiencies of clinical practices and processes; • Reviewing patient medical records and both internal and external reports to identify and research possible gaps in care; • Working with clinical leadership to identify strategies to address and close identified gaps in care at the practice level; • Using the resources available to actively and efficiently identify patients appropriate for care management; • Maximizing the patients’ health, wellness, safety, and self-care through quality care management, patient satisfaction, and cost-efficiency; • Assisting center nurses and other members of the health care team by providing advice and handling emergent or urgent calls that are within the Nurse Care Manager’s scope of professional practice; • Actively managing assigned panel of chronic care patients telephonically, including:

• Developing relationships with patients as an integral member of the health care team; • Assessing patients’ physical and psychosocial needs, including establishing literacy status and identifying barriers of the patient, family, and caregivers; • Educating patients and health care team members on the importance of preventative care and care coordination; • Supporting efforts to help ensure that a complete health assessment is performed and on file for each identified primary care patient to meet individual payor contractual requirements; • Working with patients and the patients’ care teams to coordinate change readiness and needs assessment and to develop individualized treatment care plans; • Monitoring and evaluating effectiveness of the treatment care plan and modifying as necessary; • Providing expert clinical guidance resulting in transformational changes in the patients’ overall wellbeing; • Assisting patients in setting specific, measurable, achievable, relevant, and time-based (SMART) goals for self-management; • Teaching patients how to conduct self-management tasks; reporting abnormal findings to the care team; • Promoting patient engagement and self-management by involving the patient in activities to improve his or her health; • Documenting patient self-management measures, creating a mutually agreed upon care plan, and reporting progress towards identified goals; • Collaborating with patients, family members, caregivers, Physicians, and other care team members to assess the patients’ progress toward identified health care goals; • Managing various aspects of patient care (e.g., referrals to specialists, hospitalizations, emergency room (ER) visits, ancillary testing, and medication reconciliation) and assisting the patient in coordination of care; • Communicating with patients to ensure compliance with recommendations and follow-up visits; • Reviewing documentation from other providers (e.g., hospital discharge summaries), following up with the patient as necessary, and documenting conversations with and recommendations made to the patient in the electronic medical record as appropriate; • Following Patient First protocols when handling urgent and emergent calls; • Anticipating the needs of the chronic care patient population and ensuring that necessary documentation and pre-visit planning is reviewed with the patient when possible; • Instructing and encouraging patients on use of the Patient First patient portal; • Facilitating communication between members of the health care team and patients in the decision-making process; • Assessing patient barriers to complete treatment goals through motivational interviewing and assisting the patient in mitigating issues and removing barriers to care; • Overseeing the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams; • Collaborating with external case managers for additional services as appropriate; • Developing a list of medical supply and community resources available to patients, and maintaining collegial relationships with frequently used organizations; • Working with consulting Physicians, hospitals, ERs, and other frequently used health care resources to clarify roles and develop effective and efficient communication; • Facilitating, advocating, and intervening on behalf of the patient to ensure successful implementation of the treatment care plan and continuity of care; • Working as a center staff nurse as directed.

Minimum education and professional requirements include, but are not limited to, the following: • Eighteen years of age or older; • RN licensure required; RN, BSN preferred; • Ability to be licensed in all states in which Patient First operates; • Current CPR, ACLS, and PALS certifications; • Minimum of three years’ clinical experience in medical/surgical, ER, critical care, and ambulatory care preferred; • Certification as a Case Manager or experience in Case Management and Primary Care/Patient-Centered Medical Home Care or environment that coordinates care across multiple providers preferred; • Telephonic triage, coaching, or care coordination experience required; • Ability to work in a team-oriented environment; highly organized and well-developed oral, written, presentation, and interpersonal communication skills; • Demonstrates sound judgment and decision making, problem solving, and analytical skills; • Strong professional level of knowledge in comprehensive clinical assessment in the prim

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