Registered Nurse (RN) Care Manager (Req 100934)

Description

GENERAL RESPONSIBILITIES:

Using principles of Patient Centered Medical Home (PCMH), the Registered Nurse Care Manager (RN) at Whitney Young Health (WYH) will demonstrate professional nursing practice, excellent communication and critical thinking skills, self-management expertise along with outstanding customer service to promote and assist individuals to manage their health through chronic disease management, wellness promotion and early detection. The Registered Nurse Care Manager (RN) will assist in coordination and integration of medical and behavioral health by working with the patient as well as various WYH health care staff to achieve an effective continuity of care.

SPECIFIC RESPONSIBILITIES:

Age Specific Criteria

• Demonstrates knowledge, skills and abilities to provide care to the age groups served (birth and above).
• Demonstrates knowledge of normal growth and development.
• Interpret age-specific responses to treatment.
• Demonstrates knowledge of age-specific safety precautions.

Care Management

• Utilize evidence based practice standards, PCMH guidelines, knowledge of Chronic Illness, thus identifying patient with chronic conditions for coordination of care for high risk patients.
• Collaborate with providers/clinical teams to identify target patient population for care coordination based on Athena/Relevant reports, lab/diagnosis criteria, and individual recommendations.
• Collaborate with care team regarding patient plan of care issues, testing or specialty referrals that require the Care Manager to assist/follow patient in navigating complex health systems.
• Coordinate process for outreach to patients with care opportunities to ensure no gaps to care.
• Registered Nurse will initiate a Transition of Care follow up phone calls for hospital/ER discharge and schedule patient to see primary care provider. Care Manager will follow and develop a patient engaged plan of care for all high risk patients with chronic conditions that pose a risk for readmission to hospital or ED.
• Collaborate with on-sight pharmacist to see patients for Transition of Care (Hospital discharge/ED); to provide medication reconciliation and educate patient to medication use/side effects.
• Initiate pre-visit/post visit planning, anticipate the coordination needs of the patient panel, and delegate the task of obtaining necessary documentation, lab tests, consult reports and hospital/ER discharge papers prior to patient visits
• Evaluate patient visit lists at least a week prior to day of appointment to begin care coordination/care management. Consider need to meet with patient at time of appointment (in-person) or via phone to engage patient to a patient engaged plan of care accompanied with patient specific goals. Registered Nurse (RN) Care Manager ensures patients are provided a copy of their plan of care (documents such).
• Refer patient to appropriate education and maintenance care: Health Coach, Nutrition. Assist patient to schedule specialty referrals/follow up on all prior auth. Completion so as to not delay care. Assess Social Determinate of Health needs and refers patient to the Unite Us Platform (Referral Center) in meeting patient needs for positive outcomes.
• Educate/engage patients to evidence based self-managed, chronic disease management they can undertake to gain greater control of their health status to improve health outcomes that support a healthy life style. (consider patients desired learning style when providing education).
• Utilize technology to assist with all aspects of care: EMR documentation, disease registry, HIXNY, Unite Us Referral Platform.
• Collaborate with pre/post visit planners, Behavioral Health, Health Home Services as it relates to patient engaged in Care Management, with active participation in monthly care team meetings. Update care plan as warranted by collaborative team discussion.
• Adheres to CMS guidelines as it relates to care coordination, care plan management: ensuring patient has a copy of patient engaged care plan and goals, along with patient education and appropriate documentation of such.
• Ensures patient care safety thus utilizing Adult Protective Services and or Child Protective Services to assist in ensuring patient safety. Registered Nurse (RN) will ensure compliance with local, state DOH, and federal regulations (OSHA, NCQA, NYSDOH, HRSA, CMS)

Operation/Planning

• Emergent Needs: assist team with patient care activities (initial check in/room patients, perform nursing assessment, triage patients, obtain vital signs, assist Providers with office visit needs.
• Consistently follows established protocols, clinical guidelines and infection control guidelines with any