What are the responsibilities and job description for the RN Care Manager position at CommWell?
GENERAL REQUIREMENTS
• Identifies patients within the patient panels that meet criteria for care management program.
• Reviews the patient’s chart to assign acuity level
• Assigns the patients to the appropriate care team
• Provides oversight to the Care Coordinators who are administering the comprehensive assessment and supervises the development of the Care Plan for patients who have agreed to participate in Care Management Services.
• Develops and maintains positive relationships with patients, caregivers, providers, colleagues, community and stakeholders.
• Assists staff and providers with understanding and implementation of the PCMH concept.
• Assesses the healthcare, educational and psychosocial needs of the patient and family.
• Develops and updates care plans in collaboration with the patient, PCP and other members of the health care team.
• Ensures all aspects of transitions of care are complete. This may include medication reconciliation, testing that may be ordered, specialist appointments, barriers to care and educational needs.
• Provides follow-up with patient and family to ensure a smooth transition of care has taken place.
• Collaborates with community partners to ensure open lines of communication for transitions and coordination of care, including emergency departments and hospital discharges.
• Coordinates care and manages transitions to reduce health care cost for CWH patients by implementing strategies to reduce inappropriate ED use, hospital admissions and readmissions.
• Demonstrates excellent written, verbal and communication skills, positive relationship building skills and critical analysis skills.
• Works closely with the Director of Care Coordination with implementation and other projects
• Helps with monitoring quality outcomes and identify areas for improvement.
• Other duties as assigned
Required Skills
CERTIFICATIONS AND LICENSURES
• Current NC Registered nurse license
• Current NC driver’s license
• BLS Certificate from American Red Cross or American Heart Association
