Rn Care Manager - Bay Area California

The Registered Nurse Care Manager (RN-CM) functions within the full scope of nursing practice, while leading an interdisciplinary team, in the delivery of telephonic, virtual, and in-person care, for nephrology practice patients that participate in value-based care programs. The RN-CC applies the process of assessment, planning, implementation, monitoring, and evaluation to meet the patient's health care needs across the continuum. The RN-CC serves in full collaboration with providers and health team members to ensure safe, quality, and cost-effective care.

Responsibilities include:

• Manages a panel of patients while applying the nursing process, provider guidance, and applicable care paths to develop a holistic and patient-centric plan of care.
• Provides care coordination and frequency of contact based on patient complexity, provider input, overall needs, and nursing judgment. Always maintains a purposeful, therapeutic presence.
• Delegates care to interdisciplinary team members, based on situation, while assuming accountability for measurable, patient outcomes. Guides development of multiple health care partnerships to achieve a positive effect. Holds assistive personnel accountable to complete delegated tasks.
• Accountable for development and modification of individualized plans of care and their delivery. Uses scientific background, knowledge of motivational interviewing, change theory, and creative strategies to ensure quality, effective, evidence-based and cost-efficient care.
• Collaborates and ensures high intensity engagement with patients/families, providers and the interdisciplinary team to establish mutual goals based on the patient's needs or problems. Uses patient's perspective to support informed decision-making.
• Evaluates, compares, and interprets ambiguous and changing patient data and overall clinical presentation.
• Explores patients understanding and knowledge of current health status and provides applicable coaching and education. Understands the patient's unique perspective and assures right education, right time, right environment for learning.
• Uses knowledge of complex physiology to monitor, detect, and anticipate early and subtle health status changes.
• Demonstrates culturally congruent care and evidence-based practice.
• Facilitates patient/family conferences to review treatment goals, optimize resource utilization, provide family education, and identify overall needs.
• Prioritizes engagement and patient contact upon care transitions and/or an unplanned 'crash' start to dialysis.
• Coordinates care across the continuum to assure appropriate utilization of clinical and community resources, in conjunction with other members of the care coordination team.
• Leads and presents patients at Interdisciplinary Rounds.
• Effectively manages patients through the Transitional Care Management workflow.
• Act as a patient's advocate, liaison, and information resource. Escalates all appropriate, critical information to applicable providers and care team members, in a timely manner.
• Monitors, trends, and documents patient's response to disease, illness, treatment, and overall plan of care. Provides progress updates to providers and care team, as appropriate.
• Identifies actual or potential variances in standards of care and system problems that could lead to errors, delays in care, complications, or increased cost.
• Supports patients' care coordination needs both telephonically, virtually, and in-person, based on assessment and nursing judgement.
• Meets with patients in practice and attends office appointments, as applicable.
• Develops cohesive and strong team-oriented relationships with providers and office personnel.
• Performs a majority of the work in-office with patients, providers, and practice staff.
• Facilitate projects and presentations designed to develop and improve the role of the RN case manager in the value- based care programs.
• Act as resource and representative for value-based care at health fairs and professional seminars as assigned.
• Assists with coverage for PTO and open positions as requested.
• Serves as a preceptor when assigned.
• Perform other duties and responsibilities as required, assigned, or requested.

Qualifications:

• Degree in Nursing from an accredited institution. BSN preferred.
• Active, unencumbered clinical level of licensure in the state of practice and/or nursing compact licensure.
• Active and unsanctioned driver's license.
• Basic Life Support (BLS) Provider based certification.
• Minimum of 7 years of recent experience working in the healthcare industry preferred.
• Minimum of 5 years of nursing experience working with the chronically ill (CKD/ESRD preferred).
• Home care, case management, ambulatory nursing, and/or hospital experience preferred.
• Requires working knowledge of Microsoft Office products.
• Requires experience with medical records documentation.
• Knowledge of, and experience with, electronic medical records systems
• High level of comfort communicating with patients and team members through virtual platforms such as Zoom and Microsoft Teams.
• Patient-focused.
• Continuous learner.
• Outcome oriented.
• Highly organized with ability to keep accurate schedules, notes, and records.
• Adaptive and responsive to a changing work environment.
• Strong interpersonal skills.
• Excellent written and verbal communication skills.
• Ability to multi-task and work independently.
• Thrives in a team dynamic and fosters teamwork and respect.
• Can develop and adapt procedures and processes with minimal supervision.
• Commits to the mission, vision, and values of Panoramic Health and to the profession of nursing.

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