Registered Nurse (RN) Care Manager - Women's Health / Pediatrics

GENERAL RESPONSIBILITIES : Using principles of Patient Centered Medical Home (PCMH), the Care Manager (RN) will demonstrate professional nursing practice, excellent communication and critical thinking skills, self-management expertise along with outstanding customer service to promote and assist individuals to manage their health through chronic disease management, wellness promotion and early detection. The Care Manager (RN) will assist in coordination and integration of medical and behavioral health by working with the patient as well as various WYH health care staff to achieve an effective continuity of care. SPECIFIC RESPONSIBILITIES : Age Specific Criteria Demonstrates knowledge, skills and abilities to provide care to the age groups served (birth and above). Demonstrates knowledge of normal growth and development. Interpret age-specific responses to treatment. Communicates to patients in an age-appropriate manner. Demonstrates knowledge of age-specific safety precautions. Care Management Utilize evidence based practice standards, PCMH guidelines, and knowledge of chronic health conditions to identify patient for care coordination services. Collaborate with providers / clinical team members to identify target patient population for care coordination. The RN Care Manager supports the primary care physicians in population health management by focusing care coordination attention on the at-risk population driving utilization and costs to improve efficiency, quality and patient satisfaction. Engages physician and practice team in proactive patient management by addressing medical / psychosocial / functional health care needs, follow-up, and referrals. Utilizes a designated patient roster report to review at risk population with providers to prioritize program enrollment, care planning, addressing prognosis and potential palliative / hospice care referrals. Collaborate with care team regarding patient plan of care issues, testing, or specialty referrals that require the Care Manager to assist / follow patient in navigating complex health systems. Develops comprehensive care plans in collaboration with patient, providers, and other members of the health care team based on evidence-based best practice for chronic condition management. Creates a patient-centered care plan that addresses problems / barriers and develops action plan relevant to obstacles in chronic condition management. Refers patients to appropriate community resources and support programs. Works with patients to support health-related behaviors. Uses coaching methods to assist with lifestyle management. Provides guidance on strategies and skills aimed at symptom stabilization and prevention of condition progression. Aims to improve the individual’s overall quality of life by supporting treatment goals, empowering them to be advocates for themselves and assisting them to obtain benefits, access to health care and connect to social and community services. Advocates for patients and families, responds to and facilitates resolution of patient questions and concerns. Works collaboratively with other professionals to maintain a team-oriented approach to care management and incorporates shared decision making in all patient interactions. Reviews at risk patients with providers to understand current treatment plan, future course and prognosis. Ensures advance directives and appropriate referrals are addressed, such as palliative / hospice. Operation / Planning Consistently follows established protocols, clinical guidelines and infection control guidelines with any patient interaction. Consistently identifies patient / family educational / learning needs regarding illness / care. Practices cultural humility to engage patient to plan care plan and set goals for positive health outcomes. Cognizant of language needs / health literacy levels for patient teaching. Recognizes and communicates changes in patient condition to providers in a timely manner. Participates in quality improvement activities to improve patient outcomes and reduce gaps in care. Adheres to CMS guidelines as it relates to care coordination, care plan management : ensuring patient has a copy of care plan and goals. Data Collection / Documentation Documents clear, concise, timely notes that addresses patient problems, barriers, goals, support systems, advance directives, transition plan and case management interventions to improve efficiency, quality and reduce cost in the electronic health record Consistently utilizes available resources to validate information and / or assessments when needed. Consistently utilizes documentation as a tool of communication. Documentation accurately reflects nursing assessments, interventions, treatments, and medications. Implementation Performs accurate basic physical assessments. Demonstrates knowledge of current immunization / preventative care needs and practices. Collaborates with multidisciplinary team to identify patient needs and closes the loop to prevent gaps to care. Demonstrates acceptable technical skills in providing patient care. Administers medications safely in accordance with relevant policies. Demonstrates initiative and flexibility with assignments. Assists, as needed, with clinic workflow and procedural needs. Considers patient age, disabilities, language and cultural needs and special needs with all care rendered. Professional Expectations Excellent interpersonal skills, flexible, organized, results oriented, a hard worker, a quick study, good with details and have integrity. Demonstrates excellence in both internal and external customer service, along with patient engagement. Understands and is able to effectively communicate HIPAA compliance, corporate compliance and client confidentiality. Ensures and / or remains in compliance with local, state, and federal regulation (FQHC), i.e. DHHS HRSA, CMS guidelines, and NYSDOH (article 28), and all accreditation standards (e.g. Joint Commission and NCQA-PCMH). Adheres to the National Patient Safety Goals as defined by the Joint Commission / NCQA and Whitney M. Young Jr. Health Center. Completes other duties as assigned such as continued education. Requirements RN CARE MANAGER I : Salary range : $65,000 - $75,000 annually Minimum Qualifications : Associates degree in Nursing / graduate of a registered approved program for Registered Professional Nurses with current NYS registration. Two (2) years’ experience in a health care setting. One (1) years experience working with patients with chronic conditions or care coordination in a medical setting. Demonstrated excellent customer service, good communication, and interpersonal skills. Beginner to intermediate proficiency with computer use; B.L.S Certification Preferred Qualifications : Case Manager (CM) certification. Flexibility to adjust to schedule changes. Knowledge of managed care requirements. Bilingual. RN CARE MANAGER II : Salary range : $76,000 - $87,000 annually Minimum Qualifications : Bachelor’s degree in Nursing / graduate of a registered approved program for Registered Professional Nurses with current NYS registration. Three (3) years’ experience in a health care setting. Demonstrated excellent customer service, good communication, and interpersonal skills. Beginner to intermediate proficiency with computer use; B.L.S Certification Preferred Qualifications : Two (2) years’ experience working with patients with chronic conditions or care coordination in a medical setting. Case Manager (CM) certification. Flexibility to adjust to schedule changes. Knowledge of managed care requirements. Bilingual. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other legally protected status.