RN Care Manager - Transition of Care

Job Description

Job Description

Evergreen Health

At Evergreen and our affiliates, we value collaborative, down-to-earth individuals and encourage self-expression. We recognize that our diverse workforce allows us to provide culturally competent care to everyone in our community.

The RN Care Manager - Transition of Care supports implementation of the patient’s integrated care plan and works towards resolution of patient needs / barriers. The RN Care Manager facilitates communication between patients, their families, caregivers, providers, and other members of the health care team. The RN Care Manager carries out delegated functions related to disease states and other conditions that have been deemed to be part of the scope of practice for unlicensed staff members. Their focus is to offer individualized assistance to patients, as well as their families and caregivers to overcome health care system and community barriers and facilitate consistent and timely medical care across the continuum of care

As part of the essential functions of this role, the RN Care Manager - Transition of Care :

• Develops a plan of care utilizing clinical quality indicators for all patients on case load, including but not limited to patients with diabetes, hypertension, Coumadin management, complex and comorbidity, etc.
• Provides case management, care coordination, and patient education to ensure continuous and comprehensive care for patients on case load.
• Regularly evaluates plans of care with patients, providers, and Care team as needed, develops mutual agreed upon goals, and provide patient education and behavior change coaching.
• Works collaboratively with the health care team including the providers, pharmacists, dieticians, behavioral health specialist, other nursing staff and medical assistants.
• Completes transition of care (TOC) follow up from inpatient settings to home and performs follow-up activities with patients as needed after emergency department visits. Including, develops plans of care for hospital transitions to identify factors to decrease the likelihood of readmission.
• Completes Annual Wellness Visit (AWV) components in conjunction with PCP.
• Ensures case management is implemented and managed to improve continuity and quality of care.
• Maintains communication with patients on case load concerning treatment progress and diagnostic reports.
• Identifies and coordinates referrals to community resources in regards to patient need.
• Completes documentation of all professional activities, contacts and observations promptly and appropriately.
• Attends internal and community meetings as assigned and participates in Quality Improvement activities.
• Regularly participate in cross-functional team meetings aimed at improving patient outcomes and in care team huddles to identify priorities, tasks and interventions.
• Acts as an advocate for the patient in all activities including nursing assessments, care coordination, care plan development, and communication.
• Meets regulatory and agency policy and procedures related to the practice and documentation of case management activities.
• Assists with all routine nursing duties as requested or required, including acting as an RN in clinic or through telephone triage.
• Thoroughly records information with the EMR to meet clinical and agency requirements.
• Actively strives to improve patient service delivery through participation in QI / QA activities. Attends and participates in all in-services and educational conferences provided by staff and outside vendors.

Qualified Candidate will have a current license as a Registered Nurse in New York State, with Bachelors of Science in nursing (BSN) preferred. Possession of Basic Life (BLS) Certification required. At least (3) year of experience working in an medical office setting, preferably in an HIV / AIDS or other infectious disease practice. Candidate must have familiarity with computers, EMR software (Medent), and MS Office software (Outlook, Word). Candidate must possess valid NYS driver license and insured, dependable car to use for traveling between office sites. Previous experience providing training is preferred; awareness of and sensitivity to the issues and health disparities faced by underserved populations is essential

Job Type : Full-time

Required license : Registered Nurse in New York State

Required Education : Bachelor of Science in Nursing (BSN) OR a documented plan to complete a BSN within NYSED's RN BSN requirement timeframe OR have Associate degree / license dates meeting NYSED’s exemption requirements

Required certification : Basic Cardiac Life Support (BCLS)

Preferred experience : Three (3) years of medical office setting, as well as prior experience providing training

What Evergreen Health Offers You :