Ambulatory Care Manager RN
Description
Summary:
Under the direct supervision of the Manager of Ambulatory Care Management, the care manager, registered nurse (RN) serves in an expanded nursing role to coordinate and provide care management services to patients at all risk levels. The care manager (RN) collaborates with primary care providers in multiple practice sites to facilitate clinical guideline adherence and to coordinate services specifically related to patients' healthcare needs. The care manager (RN) integrates identified needs of patient, education pathways, clinical guidelines, and diagnostic tests to develop individualized plans of care.
Responsibilities:
1. Assesses, plans, implements, coordinates, monitors, and evaluates all options and services with the goal of optimizing the patient's health status. Assesses healthcare, educational and psychosocial needs of the patient and their family.
2. Integrates evidenced-based clinical and preventative guidelines, protocols and other metrics to develop treatment plans that are patient-centric. Promote quality and efficiency in the delivery of healthcare for the population served. Uses established education pathways to facilitate comprehensive and consistent condition management education to patients.
3. Assesses patient at the point of disposition to optimize patient centric plan of care. Identifies the targeted population and stratifies risk of all patients to prioritize needs and direct interventions. Ability to provide Transitions of Care.
4. Designs an individualized plan of care with the patient and fosters a team approach by working collaboratively with the patient, family, primary care provider, and other members of the healthcare team to ensure coordination of services.
5. Demonstrates ability to work autonomously and be directly accoutable for results. Collaborates with primary care providers to enhance evidence-based clinical guideline adherence and promote best practices by initiating/adjusting therapies as directed by the provider providing appropriate follow-up and monitoring as needed. Facilitates/coordinates laboratory and diagnostic tests for all condition management programs.
6. Evaluates patients' progress toward desired heatlh outcomes and adjusts plan of care for optimal outcomes.
7. Collects, documents and analyzes data (pre-visit planning) communicating results/documents as required for care management programs.
8. Maintains patient confidentiality with all activities in the care management programs.
9. Identifies problems, proposes process improvement strategies, and assists the care management team in quality improvement activities.
10. Collaborates with other disciplines at practice sites to identify operational issues and performance improvement needs.
11. Attends and participates in professional and nursing continuing education programs as needed to support the care management programs and professional development. Reviews current literature on effective teaching/learning strategies and incorporates appropriate techniques into their patient education sessions.
12. Provides support to other members of the care management team
13. Performs other duties as required or assigned by emergency or other operational reasons for which the employee is qualified to perform.
14. Fulfills all compliance responsibilities related to the position.
15. Performs other duties as assigned.
Other Information:
Required: Requires ability to travel and manage fluctuating work hours. Current valid driver�s license and access to a good working vehicle are required for appropriate home visits Demonstrates excellent listening, verbal, written and critical thinking skills
Minimum Experience: three years
Desired: Working knowledge of insurance coverage. Experience in ambulatory/managed care. Prior case/care management experience.
Company: Nuvance Health
Org Unit: 1817
Department: Care Mgmt
Exempt: Yes
Salary Range: $40.43 - $75.10 Hourly