Registered Nurse/Care Manager

Job Description:

Sun River Health provides the highest quality comprehensive primary, preventative and behavioral health services to all who see it, regardless of insurance status and ability to pay, especially for the underserved and vulnerable. Sun River Health is a Federally Qualified Non-Profit Health Center serving communities in Suffolk, Rockland, Orange, Dutchess, Ulster, Sullivan, Columbia and Westchester County. Sun River Health is currently seeking a full-time Registered Nurse/Care Manager to join our team at our Poughkeepsie - Washington Street site.

Job Type: Full-time

Pay Range: $45.00- $50.33 hourly

$2,700 Sign-On Bonus  – Terms and Conditions Apply

Summary:

The RN Care Manager is responsible for coordinating screenings, assessments, care planning, and providing care management services to patients identified as having complex chronic care needs. Acts as a connector between patient needs and the resources provided by the care management program. The RN care manager will promote self-care management and assist with access to care. The RN care manager works with patients through direct face to face patient contact or telephonically. Provides guidance and leadership in the care management program to those in the healthcare organization as well as ensuring the patients receive the best possible care.

Responsibilities:

• Identifies, tracks and manages care for designated risk stratified patients
• Conducts initial care coordination screening eligibility and performs comprehensive risk assessment
• Works directly with patients/family members and providers to develop and implement an individualized and integrated patient care plan for patient
• Promotes clear communication amongst a care team including treating clinicians by ensuring awareness regarding patient care plans
• Adapts practice to meet individual patient circumstances considering level of health literacy and cultural and linguistic differences, ensuring that effective communication is achieved, particularly where there may be barriers to understanding
• Ongoing clinical assessment, monitoring and follow up for designated risk stratified patients
• Assessment and early identification of decompensating disease with appropriate intervention and management
• Assesses psychological needs and ability to benefit from community resources and referrals to outside agencies/programs when appropriate
• Performs medication review, reconciliation and coordination with a licensed prescriber for medication adjustment where indicated
• Provides organizational approved patient education materials including but not limited to health promotion and disease management
• Assists in the maintenance of the patient’s health, wellness and prevention of secondary disease complications by providing education, counseling and support
• Handles protective health information in a manner consistent with the Health Insurance Portability and Accountability Act (HIPAA)
• Collaborates with interdisciplinary teams to assess patient needs and deliver care to identified population upon discharge from varying clinical settings. Supports care transitions by coordination of activities needed to prevent or reduce utilization of emergency services or hospitalizations
• Ensures the ongoing and timely reassessment and follow-up of all care plans on a scheduled basis ensuring timely updating and documentation of patient progress toward agreed upon goals
• Promotes the coordination of relevant health and social care services to remove barriers related to social determinants of health

Requirements:

• Minimum Education Required: Bachelor of Science Nursing (BSN)
• Minimum Work-Related Experience: 0-1 year
• Preferred Work-Related Experience: 2-4 years
• Bilingual Spanish speaking preferred

Minimum Licensure:

• Minimum Requirement: NYS RN Licensed and CPR/Infection Control Certification

About Sun River Health

Sun River Health has a rich history of providing quality, affordable health care to communities in need. Founded in the early 1970s by four African American women in Peekskill, New York, the organization was established to address the lack of accessible health services in their community. With the help of a small federal grant, the first Sun River Health site opened its doors in 1975. Over the years, Sun River Health has grown into a comprehensive Federally Qualified Health Center (FQHC) system with over 45 locations, serving more than 250,000 patients across Hudson Valley, New York City and Long Island. Our exceptional primary care practitioners, specialists and support staff are dedicated to delivering