RN-Chronic Care Management

Job Description

Job Description

Description :

Chronic Care Management-RN

We are seeking a dedicated and compassionate Chronic Care Management-RN to join our healthcare team. This vital role focuses on advocating for and supporting patients with chronic conditions throughout their continuum of care. The ideal candidate will be committed to enhancing patient engagement, promoting disease prevention, and improving overall quality of care through effective care planning and management. Join us in making a meaningful difference in patients' lives by fostering collaborative, patient-centered care.

Key Responsibilities :

• Advocate for and assume accountability for a designated group of patients during all or part of their care continuum.
• Focus on primary disease prevention and strategies to improve health outcomes for chronically ill patients.
• Conduct outreach to engage patients actively in their health and wellness initiatives.
• Collaborate with healthcare team members to identify appropriate utilization of resources and coordinate care effectively.
• Develop, implement, monitor, and evaluate individualized care plans tailored to patient needs.
• Coordinate activities related to chronic care management, ensuring seamless communication among care providers.
• Monitor patient progress and adjust care strategies as needed to optimize health outcomes.
• Educate patients on disease management, medication adherence, and healthy lifestyle choices.

Skills and Qualifications :

We foster a collaborative and innovative environment dedicated to continuous growth and professional development. Join our team and contribute to transforming patient care through proactive management and compassionate support.

Canyonlands Benefits

Requirements :

Basic Function : This position assumes advocacy and accountability for an identified group of patients during all or part of the continuum of care. Focuses on primary disease prevention and improving quality of care for chronically ill patients and outreach to patients to be more engaged in their overall health and wellness through care planning and management. Collaborates with the health care team members to identify appropriate utilization of resources.

Essential Functions :

1. Collaborates with health care staff responsible for patient care to develop, implement, monitor and evaluate appropriate clinical care or other services to meet the needs of patient and coordinates all activities related to chronic care management.

2. Plans for, ensures access to, and evaluates the effectiveness of care at the next level of care along the continuum of care.

3. Ensures that areas of responsibility are operating in compliance, including documentation and records with all federal, state, and regulatory agencies.

4. With the primary care team, identifies patients to be case managed, assesses patient’s care requirements, modifies or coordinates modification of patient care and intervenes, as necessary.

5. Coordinates in the development and review of clinical pathway trends and shares with appropriate service and management teams.

6. Assist with monitoring of quality improvement elements including establishment of program measures and implementation of action plans.

7. Works directly with the Population Health Director and Community Health Workers to establish and implement outreach tasks and patient centered engagement.

8. Monitors trends and implements strategies to assist patient with accessing appropriate level of care.

Secondary Functions :

9. With the Community Health Worker, engages patient and family in the developing of health care strategies aimed at improving quality of life through education, empowerment, and access to appropriate health care services.

10. Maintains current knowledge of community resources and assists with patients’ access. Maintains current knowledge base in best practices and reviews evidence-based literature involving disease state management.

11. Participates in quality improvement activities.

12. Attends meetings, seminars, and conferences as appropriate.

13. Other duties as assigned by the Population Health Director or other Senior Management Staff.

Minimum Qualifications :

1. Ability to perform each essential function duty satisfactorily with or without reasonable accommodation. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

2. Valid and active Arizona state RN licensure.

3. Must possess and maintain CPR certification (minimum : BLS).

4. Associate’s degree in nursing.

5. Two years of broad clinical experience predominately in clinical nursing and case management.

6. Demonstrated knowledge of ambulatory disease state management practices and pathways, current payor contracts, and PCMH standards.

7. Possess a valid Arizona Driver’s License.

8. Ability to read, write and speak clearly understandable English.

9. Intermediate computer skills.

10. Excellent written and verbal communication and critical thinking skills.

Preferred Qualifications :

1. BSN

2. CCM (Certified Case Manager), CPHM (Certified Professional in Healthcare Management) or CPUR (Certified Professional in Utilization Review) certification preferred upon hire.

3. One to three years of experience in ambulatory disease state management or equivalent nursing experience.

4. Bi-lingual (English / Spanish / Navajo) language skills.

5. Knowledge of Microsoft programs with the ability to effectively communicate using Outlook.