If you are interested please apply online and send your resume to PBaker@mlkch.org

POSITION SUMMARY

Under the general direction of the Site Administrator Ambulatory, provides transitional and chronic care management; Identifies eligible patients, advocates for enrollment, assesses patient needs and barriers to care, then collaborates with the patient’s care team to tailor care plans, services, and resources to meet the individual needs of the patient and caregiver;Remains skilled in interpersonal communication and motivational interviewing to help promote patient and caregiver engagement and self-management; Makes routine contact based on patient complexity to help the patient and caregiver. Develop goals, monitor outcomes, and evaluate patient readiness for graduation from the program.The overall goal of the RN Care Manager is to improve the health of populations, improve the patient experience, reduce readmissions, reduce utilization of higher cost healthcare, and promote patient and caregiver engagement and self-management.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Coordinates with the Primary Care Providers, and all members of the health care team to facilitate a strong transitional healthcare pathway for the patient.
• Monitors patient’s healthcare pathway to ensure adherence, removes obstacles and identify progress toward desired care outcomes; intervenes to overcome deviations in the expected plan of care; reviews the care plan with patients in conjunction with the direct care providers; interacts with involved departments to negotiate and expedite scheduling and completion of tests, procedures, and consults.
• Works with patients and their family members to develop a personalized healthcare pathway that meets the individual’s needs on both a short term and long-term basis.
• Orients and educates patients and their families about the healthcare pathway by meeting them; explaining the role of the RNCM initiating the health plan; providing educational information in conjunction with health care team related to treatments, procedures, medications, and continuing care requirements.
• Identifies high-risk patient’s to promote coordination of services and to prevent readmissions or Emergency department visits.
• Disease Management
• Assists in the management of patients with chronic diseases following established protocols and systems for disease management in collaboration with providers.
• Assesses patient learning needs and has the ability to develop and implement individualized educational or care plans. Reviews, evaluates and revises the plan on an ongoing and timely basis.
• Communicates with a multidisciplinary team (physicians, nurses, therapists, social workers, etc.) as needed to assist with disease management.
• Develops self-management goals and monitors the progress of the goals.
• Has the ability to oversee and assist the patient with referral navigation.
• Initiates disease-specific care conferencing as needed.
• Utilizes patient communication strategies, e.g. motivational interviewing, to involve the patient in developing a plan of care, goals or other specific measures pertinent to their health condition.
• Assesses patient activation and readiness for change and uses these to develop self-management goals.
• Participates in confidence level assessments or surveys of patients to improve disease management care delivery processes.
• Documents all disease management encounters using standardized processes.