Registered Nurse Clinical Care Manager

Oakland Physician Network Services

Registered Nurse Clinical Care Manager

Title: Registered Nurse Clinical Care Manager

Department: Medical Management

Reports to: Director of Medical Management

Position: Full Time Employee 40 hours/week

Job Summary:

The Registered Nurse Clinical Care Manage is a licensed practitioner who interacts with physicians and office staff to provide care management and care coordination for patients with moderate to complex illness. The RN Clinical Care Manager:

• Serves in an expanded health care role to collaborate with PCP and patients to ensure the delivery of quality, efficient, patient centered, and cost-effective healthcare services.
• Provides self-management support and patient education.
• Assesses, plans, implements, monitors, and evaluates delivery of individualized patient care with the goal of optimizing the patient’s health status.
• Collaborates with members of the health care team to empower patients to manage their chronic conditions.

Summary of essential job functions:

• Identifies the targeted population within practice site(s) utilizing Electronic Medical Record/Patient Registry, Health Plan data, and daily Admits-Discharge-Transfer reports.
• Provides self-management support and empowers the patient to achieve optimal health and independence.
• Creates and promotes a care plan, developed in coordination with the patient, primary care physician, and family/caregiver(s). Monitors individual patient progress.
• Implements evidence-based care, chronic disease protocols and guidelines. Utilizes Health Plan data to ensure closure of gaps-in-care.
• Assesses the healthcare, educational, and psychosocial needs of the patient/family.
• Provides follow up with patient/family when patient transitions from one setting to another. Completes post hospital discharge calls: Medication reconciliation, PCP or

Specialist follow up appointment, assesses symptoms, teaches warning signs, coordinates care, reviews discharge instructions, and problem-solves barriers.

• Decreases emergency room utilization and hospital readmissions.
• Assists with advance directives, palliative care, hospice and end of life care coordination.
• Coordinates patient care by linking patients to resources; including community resources.
• Maintains required documentation for all care management activities.
• Works with practice and PO leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance the Patient Centered Medical Home.
• Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.

Skills required:

• Excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.
• Excellent customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
• Understands chronic disease management strategies and is able to implement appropriate protocols and guidelines.
• Demonstrates ability to work autonomously.
• Demonstrates ability to influence and negotiate individual and group decision-making.
• Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.
• Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving and decision-making, priority setting, work delegation and work organization.
• Computer proficiency (Microsoft Office, Registry/EMR, Database).

Minimum requirements:

• Current Michigan Registered Nurse License.
• Care management experience preferred.
• Clinical experience including but not limited to:
• Disease and Population Health Management
• Medical record interpretation
• Quality Improvement Measures

• Completion of Introduction to Team Based Care and Patient Engagement or comparable courses training required upon hire.

Disclaimer:

The above statements are intended to describe the general nature and responsibilities of this position. All employees may be required to perform duties outside of their normal responsibilities from time to time, as needed.

Job Type: Full-time

Pay: $64,920.64 - $78,184.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Work setting:

• Office

Work Location: In person