Nurse Care Manager

Summary:
Under the general supervision of the Program Manager Care Coordination the Nurse Care Manager will work on a multidisciplinary healthcare team in a primary care setting. The Nurse Care Manager is a Registered Nurse responsible for providing assessment care coordination services comprehensive screenings disease education and self-management support to high risk patients and patients with chronic health conditions. The Nurse Care Manager collaborates with providers healthcare team members community resources and the patient and their support system to develop care plans facilitate development of patient self-management skills establish behavior change goals and manage transitions of care outreach and follow-up. Success in this mission requires a culture of collaboration excellence leadership and respect.

Responsibilities:
Assists the clinic in the development and maintenance of an evidence-based stratification triage system to identify and keep current a list of highest risk patients most in need of nurse care management services.

Assist the clinic in the development of evidence-based clinical guidelines and protocols for chronic medical conditions.

Maintain a comprehensive working knowledge of community resources payer requirements and network services related to the clinic*s patient population.

Completes initial patient assessment including a comprehensive medical psychosocial and functional assessment of the patient and home setting as needed to identify key issues such as safety concerns special needs medication and medication reconciliation issues behavioral health concerns and other risk concerns.

In collaboration with the patient and their provider assists in the development monitoring and reinforcement of the patient*s self-management plan(s) and measureable behavioral change goals that promote cost-effective quality outcomes and enhanced quality of life for the patient.

Assesses and documents patient progress and barriers toward achieving behavior change goals working collaboratively with the patient and care team to remove barriers.

Utilizing a teach-back system provide detailed education at the appropriate educational level for the patient and their support system that is culturally appropriate and in the patient*s preferred language.

Acts as the liaison for the care team routing information and questions to care team members as needed identifying and connecting patient with resources as needed. Intervenes quickly to eliminate adverse patient occurrences thereby minimizing poor outcomes.

Establish and maintain a positive and trusting relationship with patient and their support system through face-to-face interactions in the clinic during home-visits and in hospital (as needed).

Coordinates treatment-planning meetings with providers and other members of the care team to develop assess and revise plans of care and behavior change goals.

Supports patient in development of self-management skills and goal achievement through education motivational interviewing use of self-monitoring tools referrals to community resources facilitation of communication with provider and care team members and other related activities.

Coordinates care and resources across providers facilities and levels of care. Facilitates successful transitions of care and conducts outreach following hospitalization and/or emergency department visits (within 24-72 hours of discharge).

Follows-up on patient*s treatment including referrals to specialists and key primary care appointments.

Conducts outreach as needed to ensure that the patient needs are being met and that they understand the course of their treatment.

Participates in quality-improvement activities care team meetings and professional self-development.

Emphasizes continuity of care thereby reducing or eliminating fragmentation duplication and gaps in treatment plans.

Interact and coordinate with insurance plans and disease management staff when applicable.

Leverage the electronic medical record and chronic disease registries to develop reports that will help identify at-risk populations prioritize patient follow-up types of services provided and track outcomes.

Perform other related duties as assigned.

Other information:

Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.

Brown University Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status. Brown University Health is a VEVRAA Federal Contractor.

Location: Rhode Island Hospital USA:RI:Providence

Work Type: Full Time

Shift: Shift 1

Union: UNAP