RN Care Manager

Description

About Us:

Navvis is a leading population health company, driving performance in value-based care. As an operating partner to some of the country’s most innovative health systems, physician enterprises, and health plans, we provide solutions that accelerate the journey to value-based care. Our approach is market-based – we respect the unique needs of populations in each community, including access to care, culture, values, and capabilities. Together with our partners, we set a new national standard in healthcare performance that delivers the affordability, quality, access, and experience that all patients deserve.

Learn more at: www.navvishealthcare.com

Department Overview:

What if we routinely asked every person involved in providing or receiving care: "What matters to you and why?" How would understanding "what matters" enhance our ability to transform health in communities and strengthen the connective process, leading to deeper levels of interaction and integration? At Navvis, we are deeply passionate about understanding what matters to people to ensure the delivery of Real-Person Care. We create an ecosystem that builds a foundation for better physical, social, and emotional health. Our Care Solutions, Analytics, Implementations, Clinical and Business Operations, and Learning and Development teams work tirelessly in partnership with our clients and stakeholders in communities to address the real-life healthcare needs people have every day.

As an RN Care Manager you will:

• Serves as the clinical bridge between the professional staff of the entire care continuum or in the community
• Monitors and evaluates the effectiveness of the care coordination plan and modifies as necessary
• Identify gaps or barriers in treatment plans and provides appropriate education to fill in those gaps
• Conducts complete medication reviews and gathers information about medication adherence.
• Consults with medical providers regarding patient concerns and or actions that may impact compliance with care plans
• Work closely with practices and patients regarding patient monitoring activities while adhering to the assigned practice's protocols

A Day in the Life:

• Responsible for performing care coordination within the scope of licensure for members with a variety of complex and/or chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum
• Conducts assessments to identify individual needs and a specific care coordination plan to address objectives and goals as identified during the assessment
• Communicate appropriate information to care providers in the continuum of care, monitors/reports utilization trends and intervenes as appropriate to ensure patients are connected with available resources
• Interfaces with Medical Directors and Physician Advisors on the development of care coordination treatment plans
• Performs patient/family/caregiver education about treatment, self-management, and medications etc.
• Documents completed tasks and progress notes in the care coordination system
• Other duties as assigned

What Success Looks Like in this Role:

• Coordinate with the patient/caregiver via phone, video or asynchronous messaging to ensure all physician appointments are made and kept, outpatient therapy is completed, lab/diagnostic testing, medication reconciliation is performed per the protocol and the patient’s physician
• Accountable for tracking and reporting of daily metrics and productivity measures to assess performance and support data-driven decision-making.
• Accountable for ensuring efficient and effective holistic approach for patients/families/caregivers across the care continuum
• Ability to maintain effective and professional relationships with the patient and other members of the care team
• Ability to effectively engage patients in a therapeutic relationship
• A personal commitment to a person-centered approach, along with strong relationship-building, communication, and active listening skills required

Requirements

We are excited about you if you have these things:

• Current, unrestricted (Wisconsin, RN) license with the ability to become multi-state licensed, as applicable
• Bachelor’s degree in nursing or Associate Degree in Nursing with 3+ years in critical care, population management, or acute care experience
• Case Manager Certification (CCM) preferred
• Registered nurse with 2+ years of complex case management or 4+ years of critical or acute care experience preferred
• Expe