NURSE CARE MANAGER

Duties and Responsibilities :

• Develops the clinical elements of an individual care plan for enrolled patients in consultation with other health team members and in line with COH standards of care.
• Monitors the patient’s health status and documents progress toward the goals contained in the plan of care, including amending the plan of care as needed.
• Works with care coordinators to implement the person-centered plan of care through appropriate linkages, referrals, and coordination with needed services and supports.
• Works with health care team members within and outside of COH, including caregivers, to ensure continuity of care and reduce fragmentation, duplications, and gaps in treatment.
• Facilitates patient empowerment and quality of life by promoting educated, independent patient choice on all aspects of care.
• Provides education to patients and caregivers to allow them to better understand health conditions, medications, and self-care skills.
• Counsels patients on the appropriate utilization of health services in order to avoid unnecessary utilization of emergency rooms and hospitals.
• Coordinates transitions between healthcare settings in order to reduce emergency department use, inpatient admissions, and readmissions.

Ensures that patients discharged from hospitals have adequate care and support.

• Coordinates with Clinical Nurse Managers / Nurse Navigators as needed, including in the management of clinically related patient complaints, unusual incident reports, HIPAA and OSHA incidents
• Communicates regularly with enrolled patients via face-to-face or telephone encounters at least once per month, as well as via the patient portal.

Meets patients where necessary in order to accomplish this goal.

• Contributes to the creation and refinement of key programmatic elements, including assessments, care plans, patient education materials, and protocols.
• Complies with all OSHA and Safety guidelines patient complaints, unusual incident reports, HIPAA and OSHA incidents.
• Assists the Director of Population Health Services in evaluating the quality of care in the program through a clinical and value lens and implements quality improvement processes to achieve desired outcomes.

Minimum Qualifications :

• Bachelor of Science degree in Nursing required
• A current, unencumbered DC Registered Nurse license with current CPR certification required.
• Primary care experience preferred.
• Care management and patient education experience preferred.
• Experience working with patients with substance use disorders and behavioral health concerns preferred.
• Knowledge of chronic disease processes and health maintenance required.
• Demonstrated cultural competence in communicating with low-income populations required.
• Ability to work with computers and electronic health records required.
• Strong verbal and written communication skills required

At COH, we understand the toll that the Covid-19 pandemic has taken on the workforce, which is why we prioritize the following well-being and work-life balance centered benefits :

• Remote work opportunities are available for many of our roles, promoting a culture of work-life balance
• 8 hour workdays, which include a paid lunch
• 11.5 paid company holidays, 1 personal floating holiday, 15 days of paid vacation (increases to 20 after 3 years of service), and 12 days of paid sick leave on an annual basis
• Annual performance based raises, up to 5% of your annual pay
• Tuition reimbursement, loan repayment for clinicians, licensing reimbursement, and continuing education unit funds for licensed staff
• Many opportunities for internal promotions and transfers across the agency as we continue to grow; we average 30+ promotions each year
• Ongoing internal leadership training for supervisors
• Diversity, equity, and inclusion training and initiatives for all staff
• Ongoing wellbeing activities, culture compact activities, and trauma informed care initiatives
• Medical / Dental / Vision Plans through CareFirst BlueCross Blue Shield;
• Life insurance, short-term disability and long-term disability insurance;
• 403(b) Retirement Plan;
• Flexible Spending Accounts for medical and dependent care reimbursable expenses;
• Transportation pre-tax payroll deduction for metro;
• Tuition Reimbursement for graduate studies;
• Employer paid lunch time;
• And much more!
30+ days ago