Nurse Care Manager

Nurse Care Manager

Requirements

• Current RN license for state in which the nurse practices.
• BLS certification for healthcare providers.
• RNs hired or promoted into this role need to have or obtain their BSN within three years of hire or promotion.
• Three years of clinical nursing experience.

Responsibilities

• Responds to physician referrals and identifies patients who meet established criteria for care management (e.g. HgA1c > 8, elevated LDL and/or B/P, Mental Health Integration referral, complex resource needs).
• Assesses family, social, cultural characteristics.
• Understands communication needs (e.g., vision, hearing).
• Assesses behavioral and family risk factors.
• Assesses barriers.
• Screens for chronic disease (e.g. depression).
• Reviews patient understanding of medication treatment.
• Utilizes a working knowledge of established care process models and other applicable standards of care.
• Provides focused patient education using established content and tools.
• Uses clinician approved and appropriately documented standing orders.
• Establishes individualized care plan including treatment goals in collaboration with patient and consistent with medical plan of care.
• Reviews care plan and assesses progress toward treatment goals and barrier at each relevant visit.
• Coordinates with care managers in other settings as appropriate.
• Provides information on enabling services (e.g., transportation).
• Maintains list of key community services agencies with contact information.
• Provides information about recommended or available services and contacts.
• Assesses readiness to change.
• Assesses and tracks patient capacity for and confidence in self-care.
• Develops self-care plan in collaboration with patient.
• Provides self-monitoring tools.
• Provides or connects patients with support programs.
• Assesses and supports patients in adopting healthy behaviors.
• Assesses and arranges treatment for mental health and substance abuse problems.
• Establishes process to monitor patient adherence to medical plan of care.
• Focuses on prevention measures consistent with established guidelines and care process models.
• Reviews and manages quality reports related to chronic disease and prevention.
• Supports clinicians in achieving quality incentives.
• Works collaboratively with referring physician and other members of care team.
• Completes pre-visit planning (review chart before visit, notify patient of tests needed before the visit).
• Facilitates advanced care planning (Advanced Directives). Establishes a process for reminder letters and phone calls.
• Supports clinicians and team to achieve personalized primary care goals.
• Facilitates transitions of care (e.g., unscheduled hospital admissions, emergency department visits, skilled nursing home).
• Tracks status of critical referrals.
• Follows up to obtain report back from referral clinician.
• In collaboration with clinician, establishes written care plan for patients transitioning from pediatrics to adult.
• Provides information on health insurance resources.
• Supervises and supports Health Advocates.
• Attends clinic team meetings and medical home meetings to assist with process design and help resolve team issues.
• Supports development of agenda for team meetings.
• Reviews data summary on regular basis.

Preferred Qualifications

• Bachelor’s degree in Nursing (BSN). Education must be obtained from an accredited institution. Degree will be verified.
• Experience in case management, utilization review, or discharge planning.