RN Care Manager - GBMA

Requirements

• Coordination of community resources
• Care Management of diverse patient populations
• Familiarity with care in an ambulatory setting
• Working knowledge of Care Management models especially in the State of Maryland
• Clinical Assessment, interviewing and patient education skills
• Participates in data collection, analysis, and reporting to facilitate comprehensive evaluation of program impact and areas to take action.
• Skill in oral and written communication to address inter- and intradepartmental concerns, solve problems, and address conflict.
• Demonstrated skill in problem solving using available resources in innovative ways.
• Computer and personal productivity skills to enable effective job performance.
• Maintains knowledge of professional standards of practice through participation in continuing education, community and professional activities, and committee membership.
• A compassionate and empathetic demeanor and a can-do attitude.
• Principal Duties and Responsibilities:
• Care Management
• Assesses patients within a defined caseload to identify clinical/medical needs or issues, financial resources, and care goals. Continues assessment of patient care management needs through frequent contact and communication with care team, patient and family.
• Actively manage assigned panel of chronic care patients (high acuity/complex) by: developing relationships with the patient as an integral member of the team and providing follow-up contact with patient as indicated to ensure compliance with recommendations-medications, lab/x-ray, specialist visits, PCP visits, dieticians, CDE, etc.
• Execute standing orders for tests and preventive services.
• Manage many aspects of the patient's care to include referrals to specialist, hospitalizations, ER visits, ancillary testing, and other services. Responsible for being available to provide telephone advice per protocol, handle urgent calls and emergent calls. Anticipate the needs of this patient population, seeing that the necessary documentation and pre-visit planning is completed or requested before patient visit.
• Prioritizes care management activities in order of greatest patient need and system need to achieve optimum quality and cost outcomes.
• In conjunction with the patient, provider, care coordinator, behavioral health care manager (BHCM), family and other members of the healthcare team, the payer and available resources makes referrals for transitions in care for the patient population that he/she manages.
• Develops and implements plan for assessment, education, goal setting and tracking outcomes.
• Reports at APC meetings providing provider care transformation metrics. Provides quality reports at meetings (e.g. patient satisfaction, quality metrics, etc.)
• Attends monthly meeting dates with providers and key staff. Provides quality reports at meetings (e.g. patient satisfaction, quality metrics, etc.)
• Participates in practice strategy and for performance improvement and innovation and LMS
• Work with all clinical teams as a resource on care management of assigned patients of the practice to include: pre-visit planning workflow to ensure care completion prior to visit whenever possible, after visit summary review with patients whenever appropriate, patient engagement to involve the patients in activities to improve their health, and patient education about self-management tasks they can undertake to gain greater control of their health status
• Colla

Benefits

Additional Information

The RN Care Manager is committed to comprehensive quality care management and coordination of clinical activities for primary care patients. This position focuses on promoting early intervention for complex patients and co-developing a plan of care that prevents unnecessary complications and negative patient outcomes. The RN Care Manager promotes population management through effective education, self-management support, goal setting, and timely health care delivery. This includes communicating with patients and their families concerning the progress of patient goals and ongoing care needs, developing and monitoring care management processes, and support of primary clinical team efforts. The Nurse Care Manager develops and maintains collaborative working relationships with all team members including Practice Manager, Lead Physician, and Care Coordinator, and Behavioral Health Care Manager to best serve the needs of the identified patient panel and primary care teams. The RN Care Manager will serve as a clinical resource to the Medical Assistant staff and Practice Manager. Education: Registered Nurse license required. Bachelor's of Science in Nursing preferred.

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