The Registered Nurse (RN) Care Manager is responsible for providing medical case management services through education, counseling, patient advocacy and coordination of services to patients of Tandem Health. The RN Care Manager will work on and promote team-based interdisciplinary healthcare in a primary care setting. The RN Care Manager will assist with setting up and implementing patient centered medical home care model and administering evidence-based health care in a new and innovative way. The RN Care Manager is responsible for providing comprehensive assessment, care coordination services, disease education and self-management support with patients who have chronic health conditions, been recently discharged from an acute care facility, and any patients in need of additional clinical support. The RN Care Manager will be integrated into the office-based health care team to work in partnership to promote patient-centered care, frequent contact with primary care providers and medical home team members, and actively participate in interdisciplinary patient-centered team meetings.
Duties and Responsibilities:
- Completes initial patient assessment, including a comprehensive medical, psychosocial, and functional assessment of the patient.
- Uses an interdisciplinary team approach to address opportunities to plan and coordinate care; acts in a supportive capacity to other team members (i.e., medical assistants, office personnel and providers) in supporting patient and the treatment plan.
- Uses population data to proactively identify patients to ensure continuity of care.
- Provides instruction, support, reporting and documentation, as required by the Association of Diabetic Care & Education Specialists (ADCES), Diabetic Self-Management Education and Support (DSMES) program, and other such programs.
- Monitors clinical data, including information from patients who participate in Remote Patient Monitoring (RPM), and works with members of the clinical team and providers to develop and implement treatment plans unique to the patients' needs.
- Assists with the maintenance of self-management education program curricula/objectives/program materials.
- Maintains licensure and any additional educational requirements for special programs.
- Attends required training.
- Helps to arrange contact with other resources needed to support the treatment plan.
- Integrates social and medical services.
- Identifies and utilizes cultural and community resources.
- Develops care management plans, interventions, and treatment goals in collaboration with patient/family; utilizes motivational interviewing techniques to assist patients with establishing self-management goals, and action plans with timeframes.
- Builds rapport and trust with patients and engages patients in problem-solving.
- Promotes success with chronic care plan.
- Coordinates care and communicates with providers.
- Reviews test results and tracks outcomes.
- Reviews medications and works with provider/pharmacist, as needed, to assist with medication management.
- Reviews patient risk issues and works with patient/family/team to reduce risk.
- Provides detailed education about patients' specific chronic illness, including the pathology, signs and symptoms, complications, and medications used in treatment.
- Works with patients and coordinates care in one-on-one or in group settings.
- Leverages electronic medical records and population health management applications to provide reporting to prioritize patient care and follow up and fosters a patient-centered environment that focuses on patient satisfaction and quality outcomes/monitoring.
- Provides ongoing follow-up and support to optimize patient retention in programs related to medical care, including, but not limited to, contacting patients in reference to missed appointments. Manages tracking and documentation systems for patients admitted to and discharged from the hospital, patients seen in the emergency room (ER), and patients transitioning from or to any other health care facility.
- Provides transition care for patients discharged from the hospital within 24 - 48 hours to prevent readmission and related complications.
- Identifies and manages the patient's primary driver (reason or problem that caused the hospitalization or ER visit); evaluates and institutes follow-up care for patients seen in the ER to prevent further disease exacerbation, untoward complications, or additional ER or hospital utilization.
- Ensures open communication regarding patient status with providers and office staff.
- Provides training to other practice staff, as needed.
- Performs other duties as assigned by supervisor.
Qualifications:
Education and Experience:
- Must be a registered nurse (RN) with a license in good standing in the state of South Carolina.
- A minimum of three (3) years nursing experience required.
- Prefer previous experience in or knowledge of case management practices and principles on interpersonal intervention techniques.
- BLS certification required.
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