RN Care Manager, Outpatient

Under the general supervision of the Director of Care Coordination, the Outpatient Care Manager serves in an expanded nursing role, collaborating with the patient's support systems and their Primary Care Providers to provide a model of care that ensures the delivery of quality, efficient, and cost-effective outpatient healthcare services. The Care Manager is responsible for assessing care plans and implementing, coordinating, monitoring and evaluating all options and services with the goal of optimizing the member's health status. This position will integrate evidence-based clinical guidelines, preventive guidelines, protocols, and other metrics in the development of treatment plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare. The applicant will identify and manage patients with complex and chronic health conditions and/or refer to other services/programs as needed. The applicant will work collaboratively with the patients’ health care team to foster optimal outcomes.

Duties and Responsibilities:

• Develops and updates individualized care plan based on comprehensive assessment of members in consultation with the patient and family/caregiver.

• Conducts ongoing communication and collaboration with patient, family/caregiver, as well as PCP and other healthcare providers.
• Assesses the healthcare, educational and psychosocial needs of the patients and family.
• Conducts ongoing monitoring of members health, safety and functional status, and progress toward establishing goals.
• Provides coordination of care during all transitions within the healthcare continuum.
• Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
• Provides patient with education/ coaching on his or her medical condition to promote self-management and support caregiving by family members.
• Reveals ability to work autonomously and be directly accountable for results.
• Incorporates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills into care management practice.
• Possess the skill to function effectively in a fluid, dynamic, and rapidly changing environment
• Displays the proven ability to positively influence behavior and outcomes.
• Protects confidentiality of data and intellectual property; insures compliance with national health information projection guidelines.
• Performs duties that may be in an embedded or remote environment.
• Serves as a role model for education and professional nursing practice. .

Position Requirements/Qualifications:

• Requires Registered Nurse with current license. CCM or CCTM a plus but not required.
• BSN preferred
• Minimum of three years recent experience to match responsibilities above such as acute care, home health or skilled nursing facility with a demonstrated working knowledge of Medicare/PPS/MDS guidelines required.
• Experience as a Care Manager required.
• Experience with IT solutions such as electronic health record, learning management or disease/care management systems a plus.
• Critical thinking skills and ability to analyze complex data sets required. General computer knowledge and capability to use computers required.