Care Management RN or LPN- Comprehensive Care

Job Description

Job Description

The Care Manager, RN manages care for high risk, chronically and acutely ill patients by collaborating with the Comprehensive Care team to monitor care and treatment of patients. This position includes coordinating, facilitating, monitoring, and evaluating interventions to achieve desired outcomes.

Monday - Friday 8am - 5pm

Full-Time / Full Benefits eligible

Reynoldsburg, OH

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES :

• Participate in taking care of high risk, chronically or acutely ill patients.
• Perform complete assessment of patient's current health status, including barriers to achieving optimal health, and available Identify potential gaps in care based on the assessment.
• Participate in the development and creation of an initial plan of care and self-management plan that highlights potential opportunities for improving clinical outcomes and / or utilization patterns. Collaborate with care team, patients, and caregivers to achieve plan of care outcomes and improve patient outcomes.
• Facilitate and monitor the developed plan of care for patients. Work with Comprehensive Care team to manage caseloads.
• Coordinate patient / family / caregiver participation in plan of care and self- Coordinate patient education to achieve plan of care using evidence-based methods.
• Perform Face-to-Face visits as necessary including home, office, and skilled rehab facility settings. Evaluate barriers to attainment of self-management goals and develop strategies to
• Provide ongoing feedback to patient primary care team through regular communication.
• Work in collaboration with inpatient, ambulatory, and community partners to facilitate continuity of
• Facilitate referrals to other disciplines, COPC resources, or community-based programs to improve patient
• Communicate with patients via phone calls or during scheduled home visits promptly. Conduct end-of-life discussions with patient / family, as
• Document in the medical record and designated case management tool to accurately reflect collaborative care planning, interventions and evaluation against defined targets and

QUALIFICATIONS :

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Experience, Education, Licensures & Certifications

Required : 5 or more years of clinical and case management experience in a hospital, home health / hospice, or managed care setting

Required : Active Ohio RN license

Required : Active Ohio driver’s license with the ability to travel throughout COPC’s service area.

Preferred : CCM certification; Bachelor's degree in nursing

Knowledge, Skills & Abilities

Office Culture

All our staff are expected to remain actively engaged in practice changes and updates.

COPC prides itself on fostering an environment that respects each employee, regardless of title or background. Collaboration between our teams is paramount in providing the best care for our patients and each other. Our staff are solution-minded and agree to be available and willing to accept all reasonable requests intended for the benefit of any patient on our service. We are committed to a culture of innovative healthcare, kindness, and mindful service.