Rn Care Manager

Job Type
Full-time
Description
We are looking for a full time (1.0FTE) RN Care Manager for our Hayward Clinic Team!
Hours : Monday-Friday 7:30am to 4:00pm
The RN Care Manager will manage high risk and chronic illness to promote whole-person, integrated, quality care. The RN Care Manager will employ a person-centered and team approach, partnering with patients and their family/caregiver(s), clinic/hospital/providers and specialty providers and other staff, and community resources.
Essential Functions of the Job:

• Conduct in-office patient visits as outlined in care plan and based on patient's health status and self-management interests
• Create and promote engagement with a care plan, developed with the patient, primary care provider and/or specialty care provider and family/caregiver(s)
• Support the delivery of integrated, whole-person care in family medicine, recovery and psychiatric care.
• Engage patients in self-management and shared decision-making
• Increase utilization of preventative care services
• Promote timely access to appropriate care to reduce emergency room utilization and hospital readmissions
• Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals
• Work with internal providers on coordinating schedules, getting a client in to other service lines as needed
• Facilitate patient access to appropriate medical and specialty providers, assisting with residential and detox referrals
• Assist with the identification of "high-risk" patients with a chronic illness and those with special health care needs, coordinate care, and track outcomes
• Assess for social drivers of health and work with Community Health Workers on integrated Care Management
• Attend all Care Management training courses/webinars and meetings - contribute to the development of the Care Management Program
• Participate in quality improvement efforts by; utilizing dashboards, tracking tools and providing quality reporting data monthly
• Follow protocols, clinical policy and procedure in collaboration with the Primary Care Provider/Specialty Care provider for chronic care management. Follows clinical guidelines protocols and policies related to all direct patient care.
• Performs in-clinic triage and medication refills
• Work with Triage Nurse team as needed to perform medication refills and triage.
• Conducts nursing assessments according to assessment tools to determine services and service level of care needed.
• Under provider direction performs and/or assists provider in inductions utilizing COWS, administers patient injections and provides education on naloxone.
• Helps monitor OB clients, talking with their OB provider about pain management for delivery and postpartum.
• Provides education about Neonatal Abstinence syndrome, support systems, and concerns
• General Education with patients about substance use, tobacco cessation, prevention, communicable disease management, new medical diagnosis
• Monitor medication adherence, including checking the PDMP, help monitor side effects, provide patient education, assist prior authorizations and prescription assistance programs
• Provide medication reconciliation and complete refill requests, including for controlled substances under direction and approval from prescribing provider
• Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care cost
• Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources
• Facilitate and attend meetings between patient, family/caregiver(s), care team, and community resources, as needed
• Other duties as assigned

Requirements
Qualifications and Education Requirements
Associates degree in Nursing required.
RN with two+ years related experience and/or training;
Evidence of essential leadership, communication, education, and counseling skills.
Local knowledge about connections to community health care and social welfare resources is desirable.
Preferred Skills
Experience with: Electronic Health Records, preferably Epic
Required Credentials, Certification, Licensure
Current, valid and unrestricted WI license to practice as a Registered Nurse.
Current CPR certification required.
Salary Description
$29.39 to $38.01 Based on Experience