Piedmont Health Services, Inc. (PHS) is a 501(c)(3) nonprofit and Federally Qualified Health Center (FQHC) in North Carolina. Dedicated to delivering top-tier, accessible, and inclusive primary healthcare, PHS has proudly served for 54 years and remains the largest community health center in central NC. Operating 10 Community Health Centers, two PACE (Program of All-Inclusive Care for the Elderly) SeniorCare facilities, and 2 Mobile Health Units, PHS extends its services to residents across five counties, including Alamance, Caswell, Chatham, Orange, and Lee.
Job Title – RN Care Manager
Department - Nursing
Reports to – Clinical Services Director
Work Location: PACE Burlington
1214 Vaughn Road, Burlington, NC 27217
Schedule: Full Time
Monday – Friday: 8:00am – 5:00pm
Required Travel: None
Duties/ Responsibilities –
- Chronic Disease Management and Patient Care.
- Complete initial, semi-annual, annual and change of status RN Assessments to evaluate health status and safety in the home for assigned patients.
- Assessments must be completed prior to scheduled IDT meetings.
- Completes assessments per PACE policy as required for patient and/or family request for services.
- Identify patients on assigned panel who are complex and high risk in need of intensive care and/or services which may include but is not limited to education, transition of care, home visits, frequent phone calls or chronic disease interventions to prevent hospitalization and maintain continued independence in the community.
- Works with provider to ensure appropriate participant chronic disease management.
- Be proactive in identifying and coordinating potential needs of patients and/or their caregiver.
- Active participant in care management meeting and comes prepared to discuss participants.
- Works independently to assess and evaluate patient or caregiver understanding of disease process, treatment plan and/or lifestyle changes to assist in the management of health care conditions, such as high blood pressure, diabetes, end of life, COPD and/or CHF.
- Serves as a resource to the entire team for the management of these patients and conditions.
- Coordinate safe hospital discharges, including but not limited to daily check ins and updates to the team when a participant is hospitalized.
- Checks in with dialysis center and documents in EMR participant progress.
- Assists in the coordination of a backup plan for inclement weather, center closures or other emergencies for participants who receive dialysis services.
- Contacts all participants who call out for their scheduled center day and documents accordingly.
- Completes and documents weekly visits to facility to check in on participant, monitor medication adherence and clinical care being provided.
- Assess, monitor and document on all participants with wounds at minimum weekly by completing wound measurements and evaluating the wound status.
- Assists in the coordination of patient care with other health care personnel and evaluates patient care measures instituted.
- Assists in the coordination of nursing care for participants in the nursing and assisted care facilities, according to program standards.
- Ensures the completion of monthly vital signs, weights and skin/foot check completion for participants on assigned panel and reviews to determine if additional nursing intervention is needed.
Qualifications –
Education: Graduate of an accredited school of nursing.
Required:
- Must possess knowledge and skills necessary to treat patients.
- Meet a standardized set of competencies for the specific position established by PHSC and approved by CMS before working independently.
- Excellent interpersonal, oral and written communication skills.
Preferred:
- Has practiced nursing in the last 3 years.
- Prefer experience in home care or long term care setting, and ideally, PACE experience.
- Two years of acute care management experience is preferred and/or 1 year of community based nursing experience.
Current/valid License: RN currently licensed in NC; present credentials which demonstrate ability to meet performance criteria for the RN position; Valid NC driver's license.
Immunizations: Be medically cleared for communicable diseases and have all immunizations up-to-date prior to beginning employment.
Pay Range: $71,088 - $90,052
EEO Statement: Piedmont Health Services, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to sex, sex stereotyping, pregnancy (including pregnancy, childbirth, and medical conditions related to pregnancy, childbirth, or breastfeeding), race, color, religion, ancestry or national origin, age, disability status, medical condition, marital status, sexual orientation, gender, gender identity, gender expression, transgender status, protected military or veteran status, citizenship status, genetic information, or any other characteristic protected by federal, state, or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.
DEI Statement: Piedmont Health Services, Inc. (PHS) endeavors to maintain an inclusive workplace, one that is reflective of the patient population that we serve and the individuals whom we employ. We strive to incorporate inclusiveness throughout our work culture, including the way that we recruit, support, and retain employees. We believe that having employees from diverse backgrounds, cultures, and experiences is an asset. It helps us to view the world through different lenses embodying the perspectives, opinions, approaches, and values that our employees bring to work daily. In fact, inclusion is woven into the very fabric of our work life, which allows our employees to perform at their highest possible potential.
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