Nurse Care Manager Contract

ESSENTIAL DUTIES & RESPONSIBILITIES:

• Functions as a liaison for patient/caregiver/family in navigating the continuum of care and serves as a patient advocate in inter-disciplinary meetings.
• Collaborates with the patient-centered medical home inter-disciplinary team including providers,

pharmacists, dentists, behavioral health providers, chronic disease specialists, community health workers, and nurse/nursing support personnel to achieve patient outcomes.

• Interacts with patients, caregivers, provider teams and the community to achieve continuity of care, coordination of services, timely follow-up, and care planning.
• Identifies early risk factors, conducts ongoing health assessments, and develops and maintains accurate care records of each referred patient within the electronic health record.
• Collaborate with health plans, hospitals, and utilize internal reporting capabilities to identify patients who have a recent hospitalization or emergency department visit. Distributes patient follow-up to the

Chronic Disease Specialists for outreach and appointment scheduling.

• Proactively identifies and addresses barriers to care. Maintain a current list of community agencies and resources to provide to patients, caregivers, and provider teams.
• Provides support services and/or appropriate referrals for patient, caregiver and family as recommended by the inter-disciplinary teams.
• Assures quality of care by adhering to evidenced-based guidelines; measures health outcomes against patient care goals; makes recommendations to the care team when necessary.
• Participates in the Quality Program through incident reporting and identifying opportunities for
• Participate in the Compliance Program through fraud, waste, and abuse prevention, detection, and reporting; and protecting patient confidentiality under HIPAA.
• Participate in the Infection Control Program through following hand washing and Bloodborne Pathogen safety and exposure protocols.
• Other duties as

TEAM MEMBER PARTICIPATION: Relay nursing-related information as appropriate. Participate in reviewing policies & procedures, etc. as assigned. Serve on committees as needed or assigned.

QUALIFICATION REQUIREMENTS:

To perform this job successfully, an individual must be familiar with the principles of care management and preventive care guidelines. Must have the ability to prioritize a case load, combining comprehensive nursing knowledge and skills with cost savings methodology and techniques. Must have the ability to interact with provider teams, healthcare professionals, and patients/caregivers/family in a professional manner. Knowledge of physical and behavioral health medications. Perform each essential duty listed above satisfactorily and with professionalism and courtesy to others, able to organize effectively and efficiently, and carry out workload. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Bilingual in English/Spanish preferred.

• Must be able to obtain a fingerprint clearance If not already obtained, Fingerprint Clearance card application must be submitted within five (5) business days of employment.
• Must be able to successfully pass a background check, a health fitness to duty and drug

EDUCATION and/or EXPERIENCE:

• Degree or Diploma as Registered Nurse or Licensed Practical Nurse from an accredited School of
• Minimum six (6) months to twelve (12) months related care management experience in a primary care ambulatory setting or equivalent nursing setting preferred.
• Experience in community liaison with Support Agencies and Non-
• Knowledge of computer and general office
• Accurate typing and orderly record keeping

CERTIFICATES, LICENSES, REGISTRATIONS:

• Current Arizona State Board of Nursing
• Care Management certification

COMMUNICATION SKILLS:

Ability to write and speak simple sentences as a means for basic communication. Ability to read and understand complex instructions, short correspondence, notes, letters, and memos. Ability to write simple and complex correspondence. Ability to read and understand documents such as policy manuals, safety rules, operating instructions, evidence-based guidelines, standards of care, and procedure manuals. Ability to effectively communicate information and respond to questions over the phone, in person and small group situations with customers, patients, public, and other employees of the organization. Ability to effectively present information and respond to questions from groups of managers, patients, customers, and the public.

SOFTWARE SKILLS REQUIRED:

Working within an Electronic Health Record. Basic Word Processing/Typing, Database, Spreadsheet.

MATHEMATICAL SKILLS:

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to use appropriate math for medication/prescription interpretation/dose calculation.

CRITICAL THINKING SKILLS:

Ability to solve practical problems and deal with a variety of known variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, or diagram formats.

SUPERVISION RECEIVED:

Under general supervision where standard practice enables the employee to proceed alone or in collaboration with the assigned provider team on routine work, referring all questionable cases to supervisor or the assigned provider team.

PLANNING:

Considerable responsibility with regards to general assignments in planning time, method, manner, and/or sequence of performance of own work; may also occasionally assist in the planning of work assignments performed by others within a limited area of operation.

DECISION MAKING:

Performs work operations which permit frequent opportunity for decision-making of moderate importance and occasional opportunity for decision-making of major importance.

MENTAL DEMAND:

Moderate mental demand. Operations requiring almost continuous attention, but work is sufficiently repetitive that a habit cycle is formed; operations requiring intermittent directed thinking to determine or select materials, equipment, or operations where variable sequences may be selected by the employee.

ANALYTICAL ABILITY / PROBLEM SOLVING:

Moderately structured. Fairly broad activities using moderately structured procedures with only generally guided supervision.

OTHER SKILLS AND ABILITIES:

Work in stressful situations in a calm, competent manner. Knowledgeable of and appropriately utilizes computer databases and documentation systems. Detail oriented and have good analytical skills.

WORK ENVIROMENT:

PHYSICAL DEMAND

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EXPOSURES

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

*OPIM: other potentially infectious materials