GENERAL SUMMARY OF DUTIES: The Nurse Care Manager ensures all patients who require chronic care management receive timely medical services, comprehensive education, intensive care coordination, with self-management support aimed at improving the patient’s health outcomes. Serves as an advocate and point of contact for patients their family and caregivers, providing resources and assistance to access healthcare services offered within the community. 

The Nurse Care Manager works in collaboration with the multidisciplinary care team to organize and coordinate patients’ care throughout the healthcare continuum. Serves as a liaison throughout the organization and with external community partners to provide patients, that are high-risk for health deterioration and/or poor health outcomes, with needed services required for health promotion.

The Nurse Care Manager ensures that the providers and care team sustains a robust role in the plan of care of high-risk vulnerable patients receiving optimal care which include acute care, chronic disease, as well as preventive care management across multiple healthcare settings.

SUPERVISION EXERCISED: Indirectly supervises Care Coordinators.

ESSENTIAL FUNCTIONS:

• Practices and maintains all federal, state, and local regulations, guidelines, protocols, and standards of care ensuring compliance and continuity of patient care.
• Institutes the principles of the Patient Centered Medical Home (PCMH) model, utilizing clinical protocols and tracking tools conjointly, under the direction of clinical leadership.
• Works across the entire organization, which requires traveling to all clinic locations.
• Work with the care team to provide timely, coordinated, compassionate interdisciplinary care.
• Assists with the coordination of care for patients transitioning to or from other healthcare facilities and/or providers.
• Assesses the patient’s physical, mental, and psychosocial needs. 
• Identify and triage high-risk patients based on the severity of disease, self-care limitations, lack of support, severe socioeconomic factors, polypharmacy, and healthcare utilization trends.
• Maintains a registry of high-risk patients with documented completion of measures and interventions.
• Initiates care management by educating and informing patients, their family and caregiver of their treatment plans, ensuring seamless, continuous and comprehensive healthcare based on their need’s assessment.
• Utilizes behavioral strategies to assist patients in adopting healthy behaviors, improving self-care and managing chronic disease(s).
• Communicates consistently with the multidisciplinary care team about the patient’s needs and/or concerns.
• Under the direction of the provider, response to the patient’s request for information regarding their disease process, treatment plan, medications, side effects, etc.
• Under the supervision of the provider, support the patient, their family and caregiver during times of difficult decision-making.
• Coordinates planning sessions with the care team to ensure all disciplines are engaged and involved in the management of patients with poorly controlled medical condition(s), who have been hospitalized and are non-compliant regarding their treatment plan.
• Systematically, logs and tracks patient referrals aimed at risk stratification and treatment plan optimization to achieve patient compliance.
• Assists the Care Coordinators with managing patient referrals, consults, support services, results and reports, notifying the providers in a timely manner for patient follow-up.
• Keeps current with all Electronic Medical Record (EMR) updates to optimize workflows.
• Assists the Care Coordinators with proper documentation and charting in the EMR.
• Develops, maintains, and updates patient’s care plans that prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, minimize hospital and Emergency Room (ER) utilization.
• Provides ongoing documentation and evaluation of the patient’s progress and risk status, updating the patient’s care plan and providing appropriate interventions.
• Provides care management and guidance for high-risk patients in jeopardy of health deterioration and/or poor outcomes to decrease hospital admissions, readmissions, and ER visits.
• Identifies and manages the patient’s primary driver (reason or problem that caused the hospitalization or ER visit). 
• Maintains a tracking and documentation systems for patients admitted and discharged from the hospital, seen in the ER, and transitioning from or to any other healthcare facility. 
• Assists patients with problem-solving, related to the utilization of healthcare systems, financial and psychosocial barriers. 
• Prepares a care team report cards and/or dashboards for quality improvement.
• Completes reports and Performance Improvement (PI) activities demonstrating patient’s outcomes as needed and/or directed.
• Serves as an educational resource, participates in health fairs conducting health screenings, in conjunction with the outreach team.
• Promotes and models professional behavior on a continuous basis, leading by example exhibiting Customer Service Excellence.
• Supports current organizational initiatives, such as Emergency Preparedness, exhibits creativity and flexibility in times of change. 
• Participates in committees, attends professional meetings and trainings as required.
• Attends continuing education programs as required.
• Performs other duties and tasks as assigned and/or needed.

QUALIFICATIONS: 

• Experienced in Case Management, Home Health, Medical/Surgical Nursing, Emergency Room or Ambulatory Care.
• Five years of nursing experience required.

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EDUCATION: Licensed Practical Nurse (LPN) with successful completion of an approved and accredited Practical Nursing program.

KNOWLEDGE, SKILLS AND ABLITIES: 

• Strong leadership, organizational and interpersonal skills. 
• Self-directed and good time-management skills. 
• Excellent communication and coordination skills, both written and orally.
• Requires excellent problem-solving and critical thinking skills.
• Strong computer skills. Proficient utilization of the EMR and Microsoft Office suite.
• Excellent presentation skills. 
• Maintains confidentiality of protected health information.
• Able to implement clinical based educational programs.
• Utilizes data and evidence-based research to achieve and improve patients’ health outcomes; as well as meeting requirements for quality measures, Joint Commission, PCMH and other accrediting bodies. 
• Manages organizational resources properly.
• Embraces concepts and behaviors that enhance customer satisfaction and engaging staff members.

CERTIFICATES, LICENSES, REGISTRATIONS:

• Must be a License Practical Nurse (LPN) with a current Louisiana State Board of Nursing license.
• Basic Life Support (BLS) Certification required.
• Certification in specialty area, if applicable.