What are the responsibilities and job description for the Care Manager -- RN position at Johnson Health?
General Position Summary: The Care Manager (CM) works with the patient population and other JHC staff to support a patient centered, model of care. The CM will assess, plan, facilitate, coordinate, and evaluate patient needs and, with patient consent, create an agreed upon plan of care to facilitate medical self-management and wellness.
Essential Duties and Responsibilities:
1. Identifies patients who have complex medical issues (such as those having several diagnoses, chronic illnesses, complicated treatments, multiple providers) in order to assist and educate patients regarding their conditions and treatment plans, and aid in care coordination.
2. Advocates for patients’ health literacy and medical self-management; educates patients to empower them to be active participants in the health care and treatment options by informing and collaborating with patients regarding their health care needs.
3. Develop and implement care plans that involve patients, caregivers and family to meet health care needs. Monitors adherence to individualized plan of care.
4. Manages patient caseload based on acuity level of follow-up.
5. Promote wellness through one on one education by identifying barriers to care and assisting with lifestyle changes.
6. Responsible for building one on one rapport with patient to improve patient engagement and self- care management.
7. Monitors ER/Hospital discharge reports from the hospital to assist with coordination of care and Transitional Care Management after discharge. Assesses discharge information and connects the patient with healthcare professionals; educates and supports treatment regimen adherence and medication management.
8. Performs medical triage as needed to provide appropriate guidance through education and scheduling of appointments based on current health status and needs.
9. Performs on-going assessment of patient needs and individual care plan by having direct patient/patient representative contact (face to face or telephone) and confers with medical staff to address gaps in medical care through patient outreach, education and coordination of care.
10. Serve as a resource for Care Management Coordinators by providing training and guidance in addressing individual patient needs.
11. Educates medical staff regarding individual patient issues and barriers as well as general health risk management and population issues.
12. Participates in patient care team meetings to maintain patient-focused care and work flow processes.
13. Facilitate patient education programs (ex: Diabetes Prevention Program) to proactively address preventable health problems and manage existing chronic health problems and works with provider care teams to identify patients who may benefit from different educational programs.
14. Works with the Director of Care Management to identify center-wide care issues and improve work processes.
15. Other clinical duties and responsibilities as assigned by the Director of Care Management.
Other Functions:
1. Staff will abide by the Code of conduct as documented in the Corporate Compliance Manual.
2. Must demonstrate a personal and professional commitment to Johnson Health Center and its mission.
3. Treats all patients and staff with dignity and respect.
4. Management may modify, add or remove any job functions as necessary, or as changing organizational needs require.
Qualifications:
1. Must be licensed with the Virginia State Board of Nursing with a current RN license.
2. Minimum of 3-5 years’ RN experience.
3. Must have graduated from an accredited nursing program. Certified Care Manager (CCM) is preferred.
4. If certified, maintains Certified Care Manager status as directed by governing agency and maintains the appropriate continued education criteria.
5. Ability to work a flexible schedule.
Physical Demand and Working Environment: Fast paced office setting with travel to other offices often. Lifting and/or exerting force up to 25 pounds occasionally, with frequently moving of objects. Work requires speaking, sitting, bending, walking, standing, hearing, and stooping, kneeling, and repetitive motion with certain activities. Up to 8 hours of constant computer usage. OSHA medium risk position.
