Posting Details

Description

An RN Disease Manager is responsible for all activities associated with Disease Management. Each nurse is responsible for care coordination for their assigned patients. In conjunction with the Care Management Team act as a resource to assist with planning care; patient education and medication management while assigned patients are hospitalized. They are also responsible for JCAHO core measure compliance. After discharge from the Hospital, they are responsible for all aspects of care coordination for an assigned group of patients. This includes telephonic assessment, patient education, patient management, and on-call responsibilities to address patient concerns or problems. The RN Disease Manager performs duties and responsibilities in a manner consistent with our mission and values. Principle Accountabilities: % of Time Spent

1. Maintains knowledge of current trends and developments in the cardiovascular field by reading appropriate books, journals and other literature. Attends related conferences and seminars. 5%

2. Serves as a resource for other healthcare professionals on the care of the pneumonia patient. 10%

3. Utilizes Program Protocols and Standards to: - Collaborate with the members of the healthcare team in the implementation of disease management care delivery methodology. 5% - Assess patient's response to medical regimen, including the detection of untoward events requiring notification of the Cardiologist, Primary Care Physician or consulting physicians. 5% - Formulate, identify need for changes, and make recommendations in the Plan of Care as appropriate.5% - Assess and evaluate clinical status reporting abnormal or significant findings to Cardiologist or Primary Care Physician. 5% - Assures that requirements of JCAHO core measures are documented in the medical record. 5% - Provide telephonic monitoring and surveillance. 35% - Assess psych/social/economic factors, lifestyle patterns and patient knowledge level. Provide or coordinate appropriate counseling concerning disease process, therapy regimen and precautions/actions that may prevent complications and improve outcomes. 5% - Assist the patient with goal setting and lifestyle modifications efforts. Evaluate patient progress towards goals. 5% - Coordinate referrals to multidisciplinary team members. Provide care plan direction and overview in order to ensure continuity of care. Maintain accurate patient, counseling and telephonic records. Provide timely progress reports to appropriate healthcare team members. 4% - Collaborate with healthcare team members in the development, collection and analysis of outcomes measures as it relates to the care delivery methodology. 4%

4. Performs other work duties as assigned. 7%

Total 100%

Education

Current licensure as a Registered Nurse in the state of Missouri Required.

BSN required.

Experience

Five years of hospital based clinical experience.

Capable of utilizing computer hardware and software for the generation of reports.

Must be able to work independently and in coordination with various other persons and professions.

Has knowledge of hospital operations, personnel roles and community resources. Must have excellent customer relations, communications and organizational skills.

Knowledge of heart failure and disease management preferred. The assessment, care and treatment provided by the RN Disease Manager will be consistent with the specific age related needs of the patient. The RN Disease Manager is competent to care for patient age groups included on their working area. This may include adults and geriatric adults.

Working Conditions

Employee is required to sit, stand or walk frequently.

Employee must lift/carry a light (1-20 lbs.) and medium (21-50 lbs.) load occasionally.

Employee is occasionally required to bend, squat, crawl, kneel, climb, lift waist to overhead.

Employee is occasionally required to reach forward and reach overhead. For repetitive action, employee is required to use both hands for simply grasping and pushing/pulling.

Employee is frequently exposed to electrical hazards and CRT terminal work. (Occasionally: 1-33%; Frequently: 34-66%; Continuously: 67-100%)

The most significant of duties are included but this does not exclude occasional work assignments not mentioned or developmental duties.

Job Relationships: Interacts regularly with patients, physicians, families and other internal and external health care providers and insurance company's representatives.

Takes direction from: Manager, Care Management

Provides direction to: N/A

Supervised by: Manager, Care Management

Mission/Values

Mission

Faithful to our Episcopal-Presbyterian heritage and its ministry of healing, St. Luke’s is dedicated to improving the health of the communities we serve.

Using talents and resources responsibly, we provide high quality, safe care with compassion, professional excellence and respect for each other and those we serve.

Vision

As an independent healthcare network, we create healthy communities in the region through our commitment to high quality, safe and personalized services.

Core Values

Human Dignity

We accept and treat all persons as being created in the image of God.

Compassion

We respond with caring to the needs of others as if they were members of our family.

Justice

We honor each person's rights and responsibilities in light of the common good.

Excellence

We set and strive to attain high standards of performance and continuous improvement.

Stewardship

We use our talents and resources wisely, with honesty and integrity.