Nurse Care Manager

Nurse Care Manager

JOB SUMMARY

True Health’s Nurse Care Manager works with providers and clinical staff to facilitate the management of patient groups to improve health outcomes. The Nurse Care Manager fosters patient engagement and adherence to the care plan to achieve evidence-based clinical objectives and goals specific to their conditions and preventative health measures. The Nurse Care Manager may also be assigned to work on select clinical projects to reduce health disparities and improve health outcomes.

The Nurse Care Manager will be assigned to the HIV/PrEP Patient Program and Mediation Assisted Therapy (MAT) Patient Program.

PRIMARY FUNCTIONS

• Works collaboratively with other members of the healthcare team in coordination of the patient’s care.
• Connects patients to relevant community resources as required, with the goal to increase satisfaction, patient health, and well-being and reduce healthcare costs.
• Guides the delegation of responsibilities to the appropriate staff member to meet the patient's needs. Ensure services comply with professional standards, state and federal regulatory requirements.
• Provides education for patients, families, and other members of the healthcare team.
• Acts as a liaison between patients, consulting physicians, referring physicians or outside agencies to coordinate patient appointments, admission, or surgery. Coordinates the exchange of information either written or verbal before and after patients are seen.
• Assist patients and family members with concern and empathy.
• Attend and participate in workgroups, program meetings and other associated meetings as scheduled.
• Perform patient outreach and schedule appointments as needed.
• Identify opportunities for gap closure on metrics tracked through the patient program and other quality initiatives.
• Assist with data mining and initiatives.
• Document accurately and promptly in the electronic medical record (EMR)
• Help maintain efficient patient flow through communication with healthcare teams.
• Answer telephone and return messages in a timely manner (within 48 hours).
• Monitor desktop and send patient letters/correspondence as applicable.
• Answer patient questions as needed within scope of practice.
• Respond to life-saving situations based on nursing standards, policies, procedures, and protocols within the scope of nursing practice.
• Educate the patient, family or caregiver, and members of the healthcare delivery team about treatment options, community resources, insurance benefits, psychosocial concerns, care coordination, etc., so that timely and informed decisions can be made.

• Assist the patient in safely transitioning care to the next most appropriate level.
• Strive to promote patient self-advocacy and self-determination.
• Ensure timely and accurate documentation in patients’ charts.
• Assist with tracking of referrals as necessary, ensuring documentation is current with necessary updates from patients and referral providers.
• This position will be tied to grants as assigned.
• Other duties as assigned

EDUCATION AND EXPERIENCE

• High School Diploma or equivalent
• Current, active and in good standing Registered Nurse license
• Current CPR certification
• 1-year experience in population health and patient education is preferred

KNOWLEDGE, SKILLS, AND ABILITIES

• Experience in telephone medical triage along with knowledge of the referral process and medication refill requests
• Knowledge of adult and pediatric primary healthcare
• Excellent assessment skills
• Ability to direct calls to other departments as needed
• Understand and strive to maintain teamwork with a positive attitude and eagerness to learn
• Ability to communicate effectively with healthcare teams
• Ability to work under pressure
• Computer competency
• Microsoft suite
• Telephone manners and excellent verbal communication
• Ability to work well with people from diverse backgrounds and cultures.

ADDITIONAL QUALIFICATIONS

• Bilingual a plus (English - Spanish).
• Up-to-date immunizations

REPORTING RELATIONSHIP

• Reports to the Director of Quality

PHYSICAL REQUIREMENTS

• Ability to sit, stand, walk, or view computer screen for extended periods of time
• Ability to use hands and fingers to handle or feel
• Ability to reach with hands or arms
• Ability to perform repetitive hand or wrist motions for extended periods of time