RN Care Manager - GBMC Health Partners

Overview

The RN Care Manager's primary responsibilities are to oversee care management and coordination of clinical activities for a defined patient population and to promote population health management through effective education, self-management support, goal setting, care planning and timely health care delivery. This will include developing and monitoring care management processes and support for primary clinical teams with these efforts. The Nurse Care Manager will work cooperatively with the Practice Manager, Lead Physician Provider of the practice, Care Coordinator, Centralized Care Coordinator(s) and Behavioral Health Consultant(s) to best serve the needs of the identified patient panel.

The RN Care Manager will serve as a clinical resource in the primary care setting.

Education

Bachelors of Science in Nursing required

• Current registration with the Maryland State Board of Examiners of Nurses as RN
• Completion of “Healthcare Provider” CPR
• Certificate or Certification in specialty related to your current practice within 3 years of hire

At least 2 years of diversified, progressive experience in acute care and/or other settings within the continuum. Ambulatory Care Management experience a plus

• Clinical assessment of patients including but not limited to;
  Social Determinants of Health, care planning, motivational interviewing, and patient education skills
• Proficiency in developing a detailed and comprehensive nursing plan of care for patients with multiple comorbidities, high risk and rising risk patients, high utilizers, the implementation of effective nursing care, patient education, metrics, LDM, evaluating data, metrics and the outcome of nursing interventions
• Analytical skills necessary to prepare and interpret reports
• Effective planning and organizational skills to effectively manage multiple priorities simultaneously
• Skills in oral and written communication to address inter- and intradepartmental concerns, problem solving and the ability to address patient needs and Social Determinants of Health
• Demonstrates problem solving skills, the ability to research and evaluate innovative ways to use community resources
• Computer, data analysis and personal productivity skills to enable effective use of EMR, e-mail, the internet, word processing, spreadsheets, presentations, and database packages
• The ability to cover other practices and multiple practices, as needed.

Clinical Practice/Care Management

• Assesses patients within a defined patient panel to identify clinical/medical needs or issues and care goals. Continue assessment of patient care management needs through care planning, frequent contact, huddles, and communication with the entire care team, patient and family
• Actively manage a defined patient panel of patients with chronic conditions and multiple comorbidities (high acuity/complex). This will include, but be limited to:
• Care planning; assist patients in setting SMART goals for self-management, teaching them self-management tasks
• Addressing urgent referrals to specialists and/or imaging
• Following-up to ensure compliance with recommendations-medications, lab/x-ray, specialist visits, PCP visits, dieticians
• Following-up with patient after hospitalizations/ER visits, in accordance with policies and procedures
• Execute standing orders for tests and preventive services
• Anticipate the needs of a defined patient panel by preparing for and participating in a care team “huddle”. This should include seeing that the necessary documentation and pre-visit planning is completed or requested before patient visit
• Works collaboratively with practice manager, providers, care coordinators, behavioral health consultants, and others, as needed in managing a defined panel of patients. Assess barriers and link to alternate resources when patient has not met treatment goals, is not following treatment plan of care, or has not kept important appointments
• Work with the care team to prevent unnecessary utilization through the following:
• Utilizing CRISP:
  Notification system for ED and hospital admissions
• Collaborating with the providers and care…