Chronic Care Manager

CHRONIC CARE MANAGER – RN

Position Summary: A family practice-based nurse who directly supports the practice’s chronic care patients under minimal supervision. Responsible for organizing, coordinating, and providing care coordination and care management services to patients within the practice who are most at risk for health deterioration and/or poor outcomes. He/she will coordinate and collaborate with other members of the care team as well as patients, family member/caregivers.

Will be an in-office position with the ability to do home visits should the need arise.

Primary Responsibilities:

· Identifies the targeted high-risk population within practice per PCP referral, risk stratification and patient lists. Includes patients with repeated social and/or health crisis.

· Assess over time the health care, educational and psychosocial needs of the patient. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.

· Act as a clinical liaison; collaborates with PCP, patient, family/caregivers, and members of the health care team, providing continuous follow up and documentation.

· Provides self-management support with a focus on empowering the patient/family to build capacity for self-care.

· Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.

Direct Patient Care:

· Conduct comprehensive assessment of patients’ needs (physical, mental, and psychosocial)

· Develop care plans to prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status and minimize hospital and ED utilization.

· Utilize behavioral strategies to help patients adopt healthy behaviors and improve self-care in chronic disease management. Promote self-management goals.

· Coordinate specialty care; follow up test results and other care coordination needs.

· Follow up with patients after inpatient and ED discharges.

· Ongoing evaluation and documentation of patient progress/risk status.

· Document in EPIC EMR; communicate effectively with care team.

Qualifications:

· Prior experience in care management, disease management, outpatient education and self-management support within the last 5 years preferred.

· Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment and patient education.

Skills:

· Comprehensive assessment, problem identification and care plan development of disease management

· Excellent assessment and triage skills. Ability to implement evidence-based interventions and protocols for chronic conditions.

· Behavioral strategies including motivational interviewing and self-management support.

· Relationship building with patients, staff, and providers.

· Must possess interest in emerging population health programs.

License:

· Active RN - Pennsylvania

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible schedule
• Free parking
• Health insurance
• Paid time off
• Retirement plan
• Vision insurance

Medical Specialty:

• Primary Care

Schedule:

• Monday to Friday

Experience:

• care management: 1 year (Preferred)

License/Certification:

• Pennsylvania RN License (Required)

Work Location: In person