Position Summary

The role of the Registered Nurse – Care Manager reports to the Director Value Based Programs. This position is responsible for the coordination of practice transformation initiatives for a group of high-risk patients within primary care locations. This position is responsible for providing direct patient care, assisting physicians with procedures, and assisting with front office duties, as needed.

Essential Position Responsibilities

• Care plan development and maintenance
• Provide medication reconciliation between levels of care (hospital, clinic, home)
• Provide screening and needs assessment
• Develop and maintain chronic-disease educational materials
• Establish productive interaction with clinic-based teams
• Support the care coordinator
• Actively coach identified patients through the teaching of self-management techniques and goal setting
• Serve as an advocate for patient and families
• Establish patient activation and engagement in preventative activities
• Address evidence-based gaps in care through active education and assist patients with the identification of community resources
• Facilitate transitional care management for high-risk patients
• Participate in the development and maintenance of evidence-based care activities
• Participate in the analysis of patient data and may assist with the application of risk stratification screening tools to meet program requirements.
• Ensure patient has received all necessary educational materials
• Productive interaction and education with the clinic-based team members
• Assisting patients in identifying community resources
• Assistance with QI projects within the clinics
• Medication Reconciliation
• Coordinate and hold PFAC meetings at least bi-annually

Qualification

• Education: Graduate of an accredited nursing program
• Licensure and Certifications: Valid registered nurse license and CPR, required.
• Experience: Previous experience in a clinic setting, preferred.