SCOPE OF ASSESSMENT AND PATIENT MANAGEMENT:
The Nurse Care Manager will have the opportunity to work on a multidisciplinary healthcare team in a community health clinic care setting. The Nurse Care Manager will be part of a program charged with working within the patient care medical home and administering health care in a new and innovative way. The Nurse Care Manager is responsible for providing comprehensive screenings, assessment, care coordination services, disease education and self-management support to patients with chronic health conditions, such as, coronary artery disease and depression.
WORK SCHEDULE DEMANDS
- The position is full-time, 35-40 hours per week, may vary when specified by the program director.
- Occasional unscheduled overtime may be required.
- May be required to work in any Family Health Services’ locations at the discretion of the Director of Quality Improvement and Compliance.
COMMUNICATION SKILLS
- Interpreting technical medical terminology daily.
- Use all available methods of communicating with patients, such as
- Interpreters, individual counseling, group discussions, written materials, and visual aids.
- Communicating and identifying cultural, social and economic character of
- the patient population served.
- Ability to communicate with staff and providers tactfully and effectively.
KEY RESPONSIBILITIES
- Works under the direct supervision of the Nursing Director.
- Complete initial patient assessment, including a comprehensive medical, psychosocial, and functional assessment of the patient, including in the home setting if needed.
- Provide detailed education about patient’s specific chronic illness, including the pathology, signs and symptoms, complications, and medications used in treatment.
- Assure that preventive screening tests are up to date.
- Establish care management plans, interventions, treatment goals – including self-management goals, and contact schedules.
- Promote compliance with chronic care plan.
- Coordinate care and communicate with multiple providers, both within and external to the practice
- Review test results and tracks outcomes.
- Review patient compliance issues.
- Work one-on-one with patients.
- Arrange group visits.
- Leverage EMR / chronic disease registry reporting to prioritize patient follow-up.
- Identify and utilize cultural and community resources.
- Develop quarterly reports on service volume, distribution of patients by plan, and types of services provided.
- Ensure open and effective communication, regarding patient status, with physicians and office staff.
- Act as liaison to hospital, long-term care and specialists.
- Attend required training and collaboration sessions [i.e., learning sessions, outcomes congress, care management collaboration meetings, and practice team meetings] as scheduled.
- Train staff on motivational interviewing
- Interact and coordinate with insurance companies’ and other external agencies’ Case and Disease Management staff, when applicable in caring for the patients within the Patient Centered Medical Home.
REQUIRED QUALIFICATIONS
- Licensed Registered Nurse from an accredited school.
- Three (3) to five (5) years’ experience in community health setting, public health, chronic disease management, community nursing, case management preferred.
- Current BLS certification
- Experience working with patients regarding their care coordination and disease management / education is preferred. Perform quality work within deadlines with or without direct supervision.
- Share best practices among all teams, serve as a medical home advocate, mentor and lead by example to support a positive work environment, and encourage other staff to do the same.
- Represent the practice in a positive manner to all patients and all applicable external clients
