Care Management RN - Comprehensive Home & Palliative Care

Central Ohio Primary Care; Westerville (OH); On-site; USD 75,000 - 100,000; Full time

Benefits offered by this job

Full benefits

Mon-Fri 8:00–4:30

Westerville, OH onsite

Job summary

Central Ohio Primary Care is seeking a Care Management RN to support the interdisciplinary care team, ensuring treatments align with the patient’s values and quality-of-life wishes. The role acts as a bridge between the patient, family, and medical team, utilizing hospice and palliative expertise to guide discussions about diagnosis and shifting from curative to comfort-focused care.

Responsibilities include comprehensive health assessments, development of initial plans of care, coordination of

Qualifications

• Active Ohio RN license required.
• CCM certification preferred; Bachelor's in nursing preferred.

Responsibilities

• Perform comprehensive assessments of patients' health status and barriers to optimal health.
• Develop initial care and self-management plans with the care team and family.
• Coordinate and monitor the plan of care, including home visits and referrals to COPC resources.
• Communicate regularly with the patient, family, and primary care team to update progress.
• Document care plans and evaluations in medical records and case management tools.

Skills

Care management

Team coordination

Communication

Home visits

Education

Bachelor's degree in nursing

Tools

Microsoft Outlook

Microsoft Excel

Job description

This position will support the interdisciplinary care team by focusing on honoring a patient's medical and personal preferences. The Care Management RN will act as a vital bridge between the patient, their family, and the medical team, ensuring that treatments align with the patient’s values and quality-of-life wishes. The ideal candidate will have strong knowledge of hospice and palliative services with the ability to lead complex, sensitive discussions with patients and families regarding diagnosis and shifting from curative to palliative or comfort-focused care.

• Full-Time/Full Benefits eligible
• Monday-Friday - 8:00am-4:30pm
• Westerville, OH
  

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

• Participate in taking care of high risk, chronically or acutely ill patients.
• Perform complete assessment of patient's current health status, including barriers to achieving optimal health, and available Identify potential gaps in care based on the assessment.
• Participate in the development and creation of an initial plan of care and self-management plan that highlights potential opportunities for improving clinical outcomes and/or utilization patterns. Collaborate with care team, patients, and caregivers to achieve plan of care outcomes and improve patient outcomes.
• Facilitate and monitor the developed plan of care for patients. Work with Comprehensive Care team to manage caseloads.
• Coordinate patient/family/caregiver participation in plan of care and self- Coordinate patient education to achieve plan of care using evidence-based methods.
• Perform Face-to-Face visits as necessary including home, office, and skilled rehab facility settings. Evaluate barriers to attainment of self-management goals and develop strategies to
• Provide ongoing feedback to patient primary care team through regular communication.
• Work in collaboration with inpatient, ambulatory, and community partners to facilitate continuity of
• Facilitate referrals to other disciplines, COPC resources, or community-based programs to improve patient
• Communicate with patients via phone calls or during scheduled home visits promptly. Conduct end-of-life discussions with patient/ family, as
• Document in the medical record and designated case management tool to accurately reflect collaborative care planning, interventions and evaluation against defined targets and
  

Experience, Education, Licensures & Certifications

• Required: 5 or more years of clinical and case management experience in a hospital, home health/hospice, or managed care setting
• Required: Active Ohio RN license
• Required: Active Ohio driver’s license with the ability to travel throughout COPC’s service area.
• Preferred: CCM certification; Bachelor's degree in nursing
• Preferred: CHPN

Knowledge, Skills & Abilities

• Must be able to perform any clinical or clerical duty as assigned skillfully.
• Must demonstrate the ability to handle stressful situations appropriately.
• Must be able to work flexible hours as needed.
• Must demonstrate ability to manage case load and document progress in a timely way as outlined by the care program assigned to each patient.
• Must maintain patient confidentiality.
• Must demonstrate a proficient driving record and up to date auto insurance as travel to visit patients is necessary.
• Knowledge of chronic and acute disease states in adults
• Knowledge of common medications used in a primary care setting including indications, dosages, and side effects.
• Knowledge of trends in healthcare, managed care, Medicaid, case management, medical management, and quality improvement.
• Proficient in computer software and usage including Microsoft Outlook and Microsoft Excel.
• Strong analytical, organizational, and time management skills.
• Ability to work independently and within a team environment with minimum supervision.
• Ability to demonstrate work toward the progress of patient-centered goals.
• Ability to develop and maintain rapport among health care professionals within individual COPC practices.
• Ability to adapt to changing environment.
• Ability to administer IM medication
• Ability to perform straight or indwelling catheter procedures, blood draw, nebulizer treatment, etc. as necessary
• Ability to provide same day or next day Home Visit’s for assessment as needed (ie., lab specimen collection, education, and treatment plans adjustments with collaboration providers.
• Excellent written and verbal communication skills; ability to communicate effectively in stressful situations.
• Self-disciplined, energetic, passionate, and innovative.
• Decision making/problem solving skills.
• Critical and ‘systems' thinker.
• Strong attention to detail.
• Training/teaching skills.
• Demonstrate awareness and ability to work alongside diverse cultures and patient populations.
• Commitment to customer service.