Centralized Medical Services - RN Care Manager - Las Vegas Market

Work Location : 1276-1284 S Nellis Blvd., Las Vegas, NV 89142

ArchWell Health is re-imagining the practice of primary care. We are putting the relationship between patient and physician at the center of a value-based model focused on outstanding patient experience, improved access, and better outcomes. In our medical clinics, we provide comprehensive primary care for senior adults with traditional Medicare and Medicare Advantage plans, focused on delivering improved quality, better patient experience and lower total cost of care.

Job Summary :

The Nurse Care Manager is responsible for helping coordinate and evaluate the management of patients with acute and chronic conditions, across the care continuum, to achieve high quality care measured by positive patient outcomes. This position will work closely with members of the care team to follow the patient from our centers into acute and post-acute facilities, as well as their home environments. The Nurse Care Manager plays a pivotal role in developing the care plan alongside the care team and then executing to achieve goals / objectives, standards of performance, regulatory compliance, and quality patient care.

Duties / Responsibilities :

• Establish a trusting relationship with patients, their families, and / or caregivers.
• Collaborate with clinical staff and other care team members to achieve patient goals.
• Reduce network costs by driving referrals to preferred groups and identifying excessive referral requests.
• Identify high-risk / complex patients.
• Assess physical, functional, social, psychosocial, environmental, learning, and financial needs and develop a comprehensive, individualized care plan based upon identified needs.
• Perform case management following the nursing process and standards of practice established by the Case Management Society of America (CMSA).
• Provide patient education, care coordination, and other interventions needed to help patients a achieve their health goals.
• Utilize Motivational Interviewing to build patient engagement.
• Evaluate progress toward patient's goal achievement.
• Communicate telephonically with hospital case managers, physical therapists (PT), social workers, patients, and families / caregivers to facilitate a safe discharge plan.
• Manage and plan for transitions of care.
• Conduct transitions of care assessment / screening, medication reconciliation, and care coordination following discharge to home.

Required Skills / Abilities :

Education and Experience :

A valid, active, unrestricted Registered Nurse (RN) license in State of employment required.

Embodies and serves as a role model of ArchWell Health's Values :

ArchWell Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to their race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected classification.