Registered Nurse (RN) Care Manager

Advocate Health Care; Rolling Meadows (IL); On-site; USD 70,000 - 110,000; Full time

Job summary

Advocate Health Care in Illinois seeks an experienced Registered Nurse to join our care management team. You will coordinate care across patient/family, multidisciplinary teams, and hospital care teams to ensure timely, quality, and cost-effective services.

The role emphasizes patient activation, SMART goal development, and seamless transitions of care with community resources. IL RN licensure and 5 years’ nursing or 1–2 years in care management are preferred, with Epic EMR proficiency.

Qualifications

• Must hold IL RN license and Bachelor’s degree in Nursing.
• Minimum 5 years’ clinical nursing or 1–2 years in care management.
• Strong communication and teamwork abilities.
• Proficient in Epic EMR and care coordination.

Responsibilities

• Facilitates communications among patient/family and care teams to resolve barriers to timely care.
• Collaborates with primary and hospital care teams to ensure quality, efficient, and cost-effective services.
• Uses evidence-based approaches to engage patients and families and to develop SMART goals.
• Identifies barriers to learning and delivery of care; reports findings and supports plans.
• Independently manages CM caseload per department expectations and regulatory requirements.
• Coordinates patient information and referrals to ensure smooth transitions of care.
• Demonstrates knowledge of age-appropriate care and growth/development principles.

Skills

Communication skills

Team collaboration

Critical thinking

Problem solving

Education

Bachelor's Degree in Nursing

Tools

Epic EMR

Job description

Needs IL RN licensure

• Facilitates communications among patient/family, multidisciplinary team, medical management team, community resources and other disciplines to anticipate, identify, evaluate, and act to resolve any potential barriers and constraints to delivery of care in a timely manner. Understands and interprets multiple contracts and contractual obligations in order to enable the care management team to achieve maximum clinical and financial outcomes.
• Collaborates with the patient/family and inter-professional team including the primary care team, hospital care team, post acute care managers, and other care partners to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. May work embedded within a provider office or telephonically working with a care team.
• Uses evidenced-based approaches to increase patient and family activation and engagement in their own care. As appropriate to the population, partners with patient and family to develop SMART (specific, measurable, attainable, relevant, time-bound) goals. Assists in the development, procurement, and adoption of patient self-management educational resources.
• Identifies potential barriers to learning and/or to the optimal delivery of care. Reports abnormal findings to the responsible provider/care team, and collaborates to develop a plan.
• Independently manages CM caseload according to department expectations. Ensures timely completion of tasks and documentation related to MCO, regulatory and contractual requirements.
• Partners with identified at-risk patients throughout the diagnosis, treatment and follow-up in order to deliver continuity of care. Anticipates the needs of the patient, recognizes and responds to changes in a patient’s status and determines priorities of patient care based on essential patient needs.
• Coordinates patient information and communication between and among the patient/family, the referring/accepting facilities and physicians, community caregivers (as applicable) and other members of ACM to ensure smooth transitions of care.
• Coordinates referrals to other internal AAH departments and/or external community resources as necessary.
• Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.

Major Responsibilities

• Facilitates communications among patient/family, multidisciplinary team, medical management team, community resources and other disciplines to anticipate, identify, evaluate, and act to resolve any potential barriers and constraints to delivery of care in a timely manner. Understands and interprets multiple contracts and contractual obligations in order to enable the care management team to achieve maximum clinical and financial outcomes.
• Collaborates with the patient/family and inter-professional team including the primary care team, hospital care team, post acute care managers, and other care partners to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. May work embedded within a provider office or telephonically working with a care team.
• Uses evidenced-based approaches to increase patient and family activation and engagement in their own care. As appropriate to the population, partners with patient and family to develop SMART (specific, measurable, attainable, relevant, time-bound) goals. Assists in the development, procurement, and adoption of patient self-management educational resources.
• Identifies potential barriers to learning and/or to the optimal delivery of care. Reports abnormal findings to the responsible provider/care team, and collaborates to develop a plan.Independently manages CM caseload according to department expectations. Ensures timely completion of tasks and documentation related to MCO, regulatory and contractual requirements.
• Partners with identified at-risk patients throughout the diagnosis, treatment and follow-up in order to deliver continuity of care. Anticipates the needs of the patient, recognizes and responds to changes in a patient’s status and determines priorities of patient care based on essential patient needs.
• Coordinates patient information and communication between and among the patient/family, the referring/accepting facilities and physicians, community caregivers (as applicable) and other members of ACM to ensure smooth transitions of care.
• Coordinates referrals to other internal AAH departments and/or external community resources as necessary.
• Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.

Licensure, Registration, And/or Certification Required

• Registered Nurse license issued by the state in which the team member practices. (IL)

Education Required

• Bachelor's Degree in Nursing or related field.

Experience Required

• Requires 5 years of experience in clinical nursing or 1-2 years of care management experience. Strong preference for case manager, telephonic nursing experience

Knowledge, Skills & Abilities Required

• Applicable certification is encouraged.
• Must be self-directed with the ability to work well independently and within a team environment while recognizing and meeting the individual needs of external and internal partners/customers.
• Ability to demonstrate excellent oral, written and interpersonal skills.
• Ability to demonstrate critical thinking, problem solving and excellent organizational skills.
• Ability to work productively and effectively in a complex environment that includes multiple changing priorities.
• Demonstrated ability to work well with physicians and other healthcare professionals in a direct and positive manner.
• Proficient computer/Microsoft-suite skills and previous Epic EMR experience.
• Ability to handle multiple responsibilities.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.