What are the responsibilities and job description for the Care Managment RN position at Esperanza Health Center?

Job Description

POSITION SUMMARY : The Registered Nurse (RN) Care Manager provides holistic care management to improve health outcomes and decrease emergency room utilization and hospitalizations of identified patient populations. Together with primary care practitioners (PCPs), the Care Management Nursing Supervisor, Community Health Workers (CHWs), and other interdisciplinary team members, the RN Care Manager develops and implements care plans and patient education, and works with team members to provide linkages for the various health and social needs of patients. The clinical aspects of this position are supervised by the Care Management Nursing Supervisor.

ESSENTIAL FUNCTIONS

Work with PCPs to develop care plans for disease management; coordinate care and complete tasks as necessary to complete care plan goals, including self-management goals.
Collaborate with health care team members (e.g, dietitian, social services).
Inform outreach specialists of patient intervention and disease-specific targets.
Perform medication reconciliation.
Initiate hospital follow-up as needed, conducting hospital visits as necessary.
Conduct patient phone calls and home visits, as necessary.
Patient education regarding disease process and general health maintenance.
Track preventive health maintenance items for patients.
Occasionally see patients alongside primary care providers when indicated, performing histories, medication reconciliation, etc.
Monitor collected data and patient progress.
Make an assessment if outreach needs to be modified or discontinued.
Play a consistent and active role in identifying project inefficiencies and finding effective, collaborative solutions to problems, with the goal of improving the quality of care.
Performs Medicare Chronic Care Management (CCM)
Assists with other care gap outreach as necessary to high-risk populations.
Ability to integrate faith and clinical practice.
Perform functional assessments of patients, as necessary.
Assist with claims adjustments, as necessary.
No on-call responsibilities; no weekend hours required.
Other duties and responsibilities as assigned.

COMPETENCIES

Self-directed and motivated.

Ability to effectively provide clinical care to socially and medically complex patients in a variety of non-traditional settings

Exceptional organizational and interpersonal skills, with attention to detail required.

Strong written oral / written communication is required.

Ability to work collaboratively in a team and manage multiple priorities, utilize effective time management skills, and exercise sound administrative and clinical judgment.

Ability to analyze systems and to develop creative solutions to problems.

Demonstrated ability to work well with people of various ages, backgrounds, ethnicities, and life experiences.

Requires the ability to travel to multiple office locations; valid driver's license and automobile that is insured.

Provides effective spiritual intervention with patients, sharing hope and salvation through Jesus Christ, sharing helpful Biblical instruction and scriptures, praying for patients, and connecting / referring to Christian churches as appropriate, according to the leading of the Holy Spirit and with the patient’s permission.

Serves all patients in a Christ-like manner, with respect, humility, love, and self-control.

KNOWLEDGE AND SKILLS

Registered Nurse license required; college graduate (BSN) preferred

Bilingual English / Spanish required.

At least 1-2 years’ experience providing clinical services.

Experience in community / outpatient setting and case management preferred.

Experience in serving the poor, urban environments; familiarity with North Philadelphia is preferred.

Ability to integrate faith and practice.

WORKING CONDITIONS

The RN Care Manager will be working both in the clinical setting within the health center and in patient homes.

Requires the ability to travel to multiple office locations within North Philadelphia.

Requires flexibility to work in situations in which the working conditions are unknown, as environments and situations of patient homes may vary.

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