Care Manager Registered Nurse; RN at Lakes Integrated Network, Inc. Buffalo, NY

Care Manager Registered Nurse (RN) job at Great Lakes Integrated Network, Inc.. Buffalo, NY.

GLIN IPA seeks a dedicated and proactive Care Manager Registered Nurse (RN) to join our multidisciplinary healthcare team. In this role, the Care Manager RN will provide patient-centered coaching and care coordination in a primary care and telephonic setting, ensuring seamless navigation for patients with complex needs. The Care Manager RN will identify at-risk patients and collaborate with providers to develop and implement processes for preventative care, transitions of care, and chronic disease management.

Using defined protocols and clinical expertise, the Care Manager RN will support patients following clinical events, address nursing care needs, and promote improved health outcomes. This role is essential in coordinating patient care, attributed to value-based contracts, and working closely with primary care providers and medical home teams to deliver high-quality, cost-effective care.

• Evaluate patients for care management services, determine the appropriate level of care coordination management for the patient
• Complete a comprehensive assessment to identify patient risk and develop a care plan utilizing clinical expertise and judgment to evaluate the need for alternative services as needed
• Work collaboratively with physicians and in-house resources, including pharmacists, registered dieticians, social workers, and other disciplines, to create a person-centered care plan with measurable SMART goals
• Monitor and update the care plan to include progress toward achieving established goals and self-management activities
• Interact with patient, family and providers, and multidisciplinary care team to assess the options of care, including use of benefits and community resources to update the care plan. Utilize developed systems, processes, and initiatives to engage patients in relevant case management activities necessary to promote wellness and care at the right place and time.
• Work collaboratively with physicians and in-house resources, including pharmacists, registered dieticians, social workers, and other disciplines, to support patient adherence to medical plan of care.
• Supervise and act as a resource for non-clinical staff (i.e., care coordinators and social workers).
• Verify that appropriate home care, hospice care, and other ancillary services (DME, infusion services, etc.) are in place and are being delivered as directed by the care team
• Coordinate necessary referrals and authorizations within care management areas
• Facilitate the information flow between the hospital, long-term care, specialists and home health representatives and the care team
• Use available data and work with physicians and office staff to help identify high-risk, high-need, and potentially high-cost patients
• Coordinate care and communicate with multiple providers, internal and external to the practice.
• Identify and utilize cultural and community resources and align with the patient’s cultural preferences as much as possible
• Ensure that members are screened for behavioral health issues, such as depression and substance abuse, and that they are receiving the necessary interventions and support.
• Facilitate any necessary follow-up behavioral health needs with local behavioral health providers.
• Attend required training and collaboration sessions [i.e., learning sessions, care management meetings, and practice team meetings] as scheduled.
• Provide and facilitate open communication with physicians and office staff regarding patient status.
• Obtain records from other physicians/labs/diagnostic centers as requested by the physicians and as needed for care coordination efforts.
• Build collaborative relationships with the internal GLIN IPA population health team, participating providers, and community resources.
• Other job-related duties as assigned.

• New York State Licensed RN
• Bachelor’s degree in nursing preferred;
  Associate degree in nursing is minimum requirement.
• 2-3 years of experience in acute inpatient care, rehabilitation, sub-acute care,…