Join an independent physician practice in Durham, North Carolina! Bull City Family Medicine & Pediatrics is searching for an experienced LPN / RN – Care Manager to join our team.

Position Summary

The Licensed Practical Nurse (LPN) or Registered Nurse (RN) - Care Manager provides intensive short-term transitional care to individuals with both physical and behavioral health conditions who frequently use the hospital for their care. This transitional care includes:

• Medication reconciliation
• Provides disease management and education
• Discuss ED/hospitalization encounters with patient to improve outcomes

JOB DUTIES

• Care Managers work in concert with the Primary Care Provider (PCP) and the community to coordinate a full continuum of health care services considering the patient’s unique social and cultural dynamics
• Assess patients for conditions and concerns that are able to be addressed through community care management
• Act as a liaison between the PCP, local Health Department (HD), Department of Social Services (DSS), local hospitals, and other community agencies by identifying, arranging, and coordinating physical and/or behavioral health care services in concert with the PCP
• Collaborate with network providers in assuring appropriate client management
• Build and maintain relationships with community service providers through collaboration, networking and educating at community functions
• Assist patients in addressing concerns as needed through referral for assessment, counseling and communication with healthcare team
• Maintain appropriate client documentation in the EHR
• Develop and implement individualized care management plans for identified clients
• Provide direct follow-up and outreach services via face to face encounter (home visit, provider office visit, or community encounter), phone or mail
• Educate clients and families on the importance of medical care management and the proper method to access care within the medical home environment
• Educate recipients about disease states to include medication adherence, prevention and risk factor reduction
• Ensure follow-up with hospital discharge instructions for high risk, high acuity, high cost recipients; ensure continuity of care
• Act as a liaison to providers to ensure the use of Evidence Based Practices
• Assist providers with coordination of services for high risk, high acuity, high cost recipients by implementing Evidence Based Practices
• Coordinate, develop and provide health care education programs and trainings
• Advocate for patients to receive services that will improve their health condition
• Assess patients’ plans of care for any duplicate or unnecessary services to control costs to payor
• Audit charts and compile data to support the disease centered initiatives
• Responsible for maintaining patient and family confidentiality in accordance with HIPAA
• Other job duties as required

QUALIFICATIONS

• Degree in Nursing
• Experience in managed care is highly preferred
• Must possess a valid driver’s license
• HEDIS Quality Measures experience
• Excellent communication and customer service skills required 
• Ability to work independently, while collaborating with other team members
• Ability to self-motivate, prioritize, and be willing to invest in a change process to improve efficiencies