Registered Nurse Care Manager

The Registered Nurse (RN) Case Manager works alongside Strive nurse practitioners to coordinate and facilitate quality, cost-effective care while minimizing fragmentation of the healthcare delivery system for CKD and ESRD patients. Acts as resource for patients and their families, the local care team, and other healthcare professionals. Services to patients are generally provided telephonically but there may be programs where on-site visits to clinics, medical offices, hospitals or visits to patient homes are required.

Essential Functions

• Collaborates with the care team to develop an individualized and comprehensive care plan for the patient.
• Proactively contacts the patient and/or clinic on a frequent basis as specified in the program details to assess their situation, provide assistance, and answer questions as necessary
• Revises and adjusts the patient care plan as needed to fit the needs of the patient. Provides updates to care team and family members.
• Identifies patient and/or clinic staff knowledge and understanding deficits regarding their specific program and situation. Provides the appropriate education, support and materials to facilitate informed decision making and understanding.
• Assesses patient conditions, in conjunction with the care team, such as the discovery of unreported medical and social conditions, or changes at home that may lead to adverse outcomes and ensures these concerns are referred to the appropriate sources for attention.
• Serves as a liaison with dialysis facilities, providing care plan updates to help streamline the transitions in care
• Maintains and updates the appropriate program software to manage and record required information and data. Generates and analyzes reports as needed for management, identifying trends, anomalies and areas of concern.
• Adheres to company and clinical guidelines to identify, review, assess and allocate patients for program participation according to their identified needs
• Participates in process improvement activities.
• Collaborates with all levels of the clinical team to improve processes, communication, and team skills needed to provide the best care to our patients
• Utilizes clinical judgment, independent analysis, critical thinking skills, time management skills and detailed knowledge of case management program

Minimum Qualifications

• Associates degree from accredited school of nursing required

• Current active licensure in any state within the US required
• Minimum of 5 years’ experience in clinical nursing required
• Current BLS certification required.
• Business travel
• Internet Connectivity - Min Speeds: 3.8Mbps/3.0Mbps (up/down): Latency <60 ms

Preferred Qualifications

• Excels at developing strong patient and family relationships that fosters engagement and best outcomes for all aspects of Strive Health’s Model of Care
• Minimum of 3 years’ experience in renal, ER, ICU, Cardiac, or Ambulatory Complex case management nursing preferred
• Certified Case Manger
• Demonstrated knowledge and understanding of data and managing clinical, financial, and patient satisfaction outcomes
• Demonstrated experience and effectiveness in a change agent role
• Proficiency with documenting and navigating electronic medical records (EMR)
• Strong computer skills and proficiency in MS Word and Outlook required