RN Care Manager Advanced Primary Care

University Hospitals Pain Management; Northern (KY); Hybrid; USD 65,000 - 90,000; Full time

Job summary

University Hospitals Pain Management is seeking a Registered Nurse Care Manager to support ambulatory and hospital-based care coordination. The role emphasizes applying the nursing process, assessing patient needs, planning and implementing care, and evaluating outcomes to improve care across the continuum.

You will facilitate communication between patients and primary care providers, contribute to chronic disease action plans and transitional care activities, and guide other team members with

Qualifications

• Active RN license required.
• Experience coordinating patient care and transitions.
• Strong communication with physicians, patients, and families.

Responsibilities

• Provide nursing care with high autonomy and clinical judgment.
• Coordinate continuity of care across hospital and ambulatory settings.
• Assist and guide staff, acting as a nursing resource and leader.
• Lead data-informed quality improvement and care planning efforts.
• Develop and implement chronic disease management plans.
• Educate patients and families on health maintenance and disease management.
• Navigate patients through health system resources and services.

Skills

Nursing

Care Management

Clinical decision making

Communication

Education

RN license

Job description

A Brief Overview

Under general supervision of the Supervisor, APC Care Management, the APC Administrator and the Ambulatory Site Clinical Lead provider (MD/DO, APRN, PA), perform as a member of the healthcare team to apply the nursing process when making nursing judgments and decisions specific to assessment, planning, implementation/delivery, and evaluation of patient care, and documenting relevant data and care processes. The RN Care Manager will facilitate communication between the patients and their Primary Care Providers. In addition, the RN Care Manager will assist with chronic disease action plans, transitional care management, Advance Directives planning, Annual Wellness Visits, and preventative care utilizing assessment skills both in person and telephonically. This RN position will be a resource for other team members and critical thinking skills are a must

What You Will Do

• Exercise professional nursing judgment appropriate to the level of care needed, and prioritizing patient acuity and workload demands. The RN Care Manager will function with greater autonomy by consistently demonstrating independent clinical decision making abilities.
• Provide patient care in a manner that demonstrates nursing knowledge and technical competence; recognize significant changes in patient’s condition/situation and take appropriate action. Communicate with patient/family including but not limited to relaying physician orders and changes in the plan of care, etc.
• Assist and provide guidance to other staff members by acting as a nursing resource; appropriately delegate duties in accordance with appropriate rules/regulations and professional standards of nursing practice; promote team collaboration in meeting the needs of the patient/family.
• Work as a leader in the Advanced Care Model in the ambulatory practice as assigned and work collaboratively with the APC Administrator and Director of APP & UHPS Nursing to drive system wide initiatives and changes
• RN care management integrated into Primary Care office responsible for managing patient’s care across the continuum
• Analyze sources of data to identify high risk patients and member groups
• Manage high risk patients including patients with multiple comorbidities or high risk for readmission
• Develop longitudinal care planning that includes assessment, planning, implementation and monitoring
• Coordinate continuity of care with patients and families following hospital admission, discharge and ER visits
• Advocate for patients by assisting in navigation of the health system
• Communicate to the care team the patient’s goals and progress
• Participate in quality improvement initiatives
• Participate on data collection team to evaluate health outcomes, trends, utilization, cost reductions, and programmatic evaluation for areas of improvement
• Provide 1 on 1 office visits for patients to implement care planning
• Provide health and disease education to patients and families, including group education opportunities
• Support patients in self-management of their disease and behavior modification interventions
• As a member of the community care team, identifies appropriate resources including specialists, facilities, and external healthcare organization supports to provide an interdisciplinary approach
• Collaborate with office staff in the coordination of individual patient care needs
• Support and facilitate advanced care planning for patients and their families
• Demonstrate proficiency and act as an expert role model in the performance of patient care

Additional Responsibilities

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.