Registered Nurse Care Manager

Overview

Registered Nurse Care Manager - Stony Brook Family and Preventative Medicine, UFPC

Location: Stony Brook, NY

Schedule: Full Time

Days/Hours: Mon - Fri 9 -5; Occ Sat (9-1) 

Salary Range: $99,806 - $110,145 (pay will be determined based on experience, preferred qualifications, and education)

Our compensation philosophy aims to provide marketable compensation programs and to compensate employees based on relevant experience and education. Individual compensation discussions begin during the hiring process and may occur during job review and promotional opportunities. Salaries vary depending on experience, education and current market for the position. Human Resources determines the external and internal equitable salary for each employee. 

Responsibilities

SUMMARY: The Department of Family, Population & Preventive Medicine seeks an RN Care Manager to provide high-quality, individualized patient care utilizing professional nursing skills and knowledge. This role involves managing care coordination, maintaining Patient-Centered Medical Home (PCMH) certification, and ensuring compliance with reporting requirements. The RN Care Manager works closely with management, providers, and patients to optimize outcomes, reduce hospital readmissions, and address gaps in care. This role involves direct patient care, care plan development, overseeing care coordination teams, assisting in workflow implementation, and ensuring adherence to quality and performance standards in accordance with professional standards and organizational policies. The RN Care Manager will also support quality improvement projects and ensure compliance with HIPAA and OSHA guidelines. 

 

Job Duties & Essential Functions:

Supervision & Team Management:

• Supervise the care coordination team and collaborate with the Director of Behavioral Health and outpatient behavioral health teams to implement processes that address care gaps.
• Manage the effectiveness of daily huddles by ensuring procedural information, care plans, and updates are disseminated efficiently.
• Recruit, onboard, and evaluate care coordination staff, and oversee performance improvement plans as necessary.
• Recruit, onboard, and evaluate nursing staff in conjunction with the RN Ambulatory Manager.

Care Coordination & Direct Patient Care:

• Provide direct patient care, including conducting appropriate patient testing, administering medications and vaccines, and documenting care in the patient’s treatment plan.
• Utilize physical assessment skills to evaluate patient needs, ensuring all patient care responsibilities are performed safely and in compliance with professional standards.
• Develop individualized care plans in consultation with treating physicians, including those for highly complex patients, and assist with social determinants of health such as transportation, unemployment, and food security.
• Provide patient education for chronic conditions such as asthma, hypertension, and diabetes and includes but is not limited to teaching patient’s appropriate inhaler use, using a continuous glucose monitor (CGM), administering GLP-1 medications, and home blood pressure monitoring.

Care Management & Transitional Care:

• Contact patients post-discharge from the emergency room to facilitate follow-up appointments and provide care re-education.
• Track care management patients in a daily spreadsheet, alerting staff and providers about upcoming care management appointments, and update care plans for chronic disease management.

Triage & Patient Communication:

• Triage patient phone calls and messages from various sources, including the call center, patient portal, providers, and home care nurses, addressing medical complaints, symptom concerns, or urgent issues (e.g., labs reporting critical values) in conjunction with the RN Ambulatory Care Manager.
• Assist with resolving patient inquiries, and manage emergency situations that may require police, CPS, or EMS intervention in conjunction with the RN Ambulatory Care Manager.

Quality Improvement & Compliance:

• Collaborate with the management team to review quality metrics, PCMH data, and customer service reports to identify and participate in quality improvement (QI) projects.
• Ensure adherence to institutional and insurance company quality measures for identifying care management needs and addressing care gaps.

PCMH Certification & Reporting:

• Maintain PCMH certificat