RN Care Manager - Telephonic Patient Navigator

Great Lakes Integrated Network, Inc.; Buffalo (NY); On-site; USD 80,000 - 93,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

401K

Vacation

PTO

Job summary

Great Lakes Integrated Network IPA (GLIN IPA) in Buffalo, NY seeks a Care Manager Registered Nurse to lead patient-centered care coordination in a primary care and telephonic setting. You will identify at-risk patients, develop proactive care plans, and collaborate with providers to drive preventive care and transitions of care.

The role emphasizes SMART-goal care planning, interdisciplinary teamwork, and adherence to clinical protocols to improve health outcomes while controlling costs.

Qualifications

• New York State Licensed RN.
• Bachelor's degree in nursing preferred; Associate degree in nursing is minimum requirement.
• 2-3 years of experience in acute inpatient care, rehabilitation, sub-acute care, skilled nursing facilities, home care, ambulatory care management, or managed health plans.
• Preferred: Certified Case Management (CCM) certification
• Preferred: Care/Case Management experience

Responsibilities

• Evaluate patients for care management services, determine the appropriate level of care coordination management for the patient
• Complete a comprehensive assessment to identify patient risk and develop a care plan utilizing clinical expertise and judgment to evaluate the need for alternative services as needed
• Work collaboratively with physicians and in-house resources, including pharmacists, registered dieticians, social workers, and other disciplines, to create a person-centered care plan with measurable SMART goals
• Monitor and update the care plan to include progress toward achieving established goals and self-management activities
• Interact with patient, family and providers, and multidisciplinary care team to assess the options of care, including use of benefits and community resources to update the care plan
• Work collaboratively with physicians and in-house resources, including pharmacists, registered dieticians, social workers, and other disciplines, to support patient adherence to medical plan of care
• Supervise and act as a resource for non-clinical staff (i.e., care coordinators and social workers)
• Verify that appropriate home care, hospice care, and other ancillary services are in place and are being delivered as directed by the care team
• Coordinate necessary referrals and authorizations within care management areas
• Facilitate the information flow between the hospital, long-term care, specialists and home health representatives and the care team
• Use available data and work with physicians and office staff to help identify high-risk, high-need, and potentially high-cost patients
• Coordinate care and communicate with multiple providers, internal and external to the practice.
• Identify and utilize cultural and community resources and align with the patient’s cultural preferences as much as possible
• Ensure that members are screened for behavioral health issues, such as depression and substance abuse, and that they are receiving the necessary interventions and support.
• Facilitate any necessary follow-up behavioral health needs with local behavioral health providers.
• Attend required training and collaboration sessions [i.e., learning sessions, care management meetings, and practice team meetings] as scheduled.
• Provide and facilitate open communication with physicians and office staff regarding patient status.
• Obtain records from other physicians/labs/diagnostic centers as requested by the physicians and as needed for care coordination efforts.
• Build collaborative relationships with the internal GLIN IPA population health team, participating providers, and community resources.
• Other job-related duties as assigned.

Skills

RN license

Care coordination

Patient coaching

Interdisciplinary collaboration

Education

Bachelor in Nursing

Associate degree in nursing

Tools

EMR systems

Outlook

Excel

Job description

Great Lakes Integrated Network IPA (GLIN IPA) in Buffalo, NY seeks a Care Manager Registered Nurse to lead patient-centered care coordination in a primary care and telephonic setting. You will identify at-risk patients, develop proactive care plans, and collaborate with providers to drive preventive care and transitions of care.

The role emphasizes SMART-goal care planning, interdisciplinary teamwork, and adherence to clinical protocols to improve health outcomes while controlling costs.