RN Care Manager Lead Primary Care Institute

Under supervision of the Supervisor, Care Management – PCI; Administrator, Value Based Programs – PCI; and Primary Care Providers, perform as a member of the healthcare team. Apply the nursing process when making nursing judgments and decisions specific to assessment, planning, implementation/delivery, and evaluation of patient care, and documenting relevant data and care processes. The RN Care Manager Lead will oversee daily operational care management activities performed by care management team members, and delegate and prioritize assignments of care management team. Ensures that care management accountabilities are carried out according to Primary Care Institute (PCI) policies and procedures.

• Provide guidance for the care management team and implement patient care in a manner that demonstrates nursing knowledge and technical competence; recognize significant changes in patient’s condition/situation and take appropriate action.
• Exercise professional nursing judgment in creating and delegating staff work assignments, and prioritizes patient acuity and workload demands for care management team
• Provide guidance to other staff members by acting as a nursing resource; delegate duties in accordance with rules/regulations and professional standards of nursing practice
• Participate in providing education to practices regarding Care Management and Transitional Care Management workflows
• Participate in the implementation of system wide initiatives and changes, and work collaboratively with PCI and Population Health Leadership
• Analyze sources of data to identify high risk patients
• Tracks, collects, and maintains data to maximize business efficiency
• Advocate for patients by assisting in navigation of the health system
• Develop or facilitate the development of patient specific care plans for longitudinal care management and/or identify patient specific interventions for transitional care management
• Educate patients and families in self-management of their medical conditions
• Assess patient post discharge needs and coordinate transitional care services to decrease risk of readmission
• Communicate with patient/family regarding nursing care plan and/or interventions, and orders by their PCP
• Communicate patient’s goals and progress to the care team
• Identifies resources including multidisciplinary care team, specialists, facilities, and external healthcare organizations to support patients
• Collaborate with office staff in the coordination of individual patient care needs
• Assist with hiring and provide orientation for Care Management staff
• Coach and develops staff, and communicate performance feedback to Supervisor
• Maintains documentation related to employee performance and participate in annual performance evaluations
• Validates employee time worked in Kronos and signs off on biweekly timecard

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.

• Graduate of an accredited school of nursing (Required) and
• Bachelor's Degree (Preferred)

• 3+ years Clinical experience (Required) and
• Experience with process improvement and program development (Preferred) and
• Experience in Chronic Care Management and Transitional Care Management (Preferred) and
• Exper