Care Manager RN

Care Manager, RN, Lehigh Valley Physicians Practice- Adult Internal Medicine

Valley Health Partners, Allentown, PA

Job Summary: Conducts assessments of patient/family needs for the highest risk patients or those patients at risk for poor outcomes. Collaborates with health professionals across the continuum; formulates a documented plan of care that ensures continuity and goal-setting that equips individuals and their families to easily access resources and adopt healthy lifestyles. This position is supported through grant funding and will be up for reapproval every 2 years.

Education:                                 

•  Bachelor’s Degree in Nursing or related field.     
• Master’s Degree in Nursing, preferred.

                                                     

Experience:                                   

•  3 years’ experience in at least one of the following settings: case management, disease management, home health care, hospital, or physician office setting and        
• 2 years’ prior electronic medical record (EMR) experience

Certificates:                                  

•  CACRN - Certified Ambulatory Care RN Ambulatory Care Manager within 3 years of hire or
• Care Coordination and Transition Management (CCCTM) or
• Relevant certification relevant to role as approved by department leadership

Licensure

•  Registered Nurse

Required Skills

• Ability to incorporate strategies for interacting with persons from diverse backgrounds.
• Effective behavioral and educational strategies such as motivational interviewing, teach-back method, and self-management support.
• Ability to set priorities to coordinate care plan efficiently.
• Ability to recognize the role of cultural, social, economic, and behavioral factors in accessibility, availability, acceptability, and delivery of public health services.

Essential Functions:

• Oversees care management functions and related tasks for a designated population.
• Utilizes computer databases and documentation systems and develops and maintains accurate case records of all patients.
• Promotes patient self-management, provides education about disease processes, and empowers patients and families to achieve maximum levels of wellness and independence.
• Evaluates medical, rehab, psychosocial socioeconomic, psychological, and physical needs and makes referrals.
• Provides medication management, including medication reconciliation during care transitions for the highest risk patients.
• Identifies issues related to the healthcare system, transportation, financial, and/or psychological barriers and works collaboratively to problem solve, coordinate services, and to advocate for patients/families.
• Provides care management for the highest risk patients to reduce risk and emergency department utilization to improve outcomes.
• Identifies patient and/or clinic staff knowledge to understand deficits regarding specific programs.
• Collaborates with all levels of the clinical team to improve processes, communication, and team skills needed to provide the best care to patients.
• Provides coordination of care for the highest risk patients experiencing a transition to or from care facilities and/or providers.

 

Benefits:

• Choice of 2 Medical Plans
• Choice of 2 Dental Plans
• Choice of a Vision Plan
• 403b Retirement Plan with company match
• Paid Time Off for holidays, vacation, sick and personal days
• Employee Assistance Program
• Tuition Reimbursement
• Company paid long and short-term disability.