Job Description : Job Description
Job Description
Clinic Network
The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands and work environment conditions.
Position descriptions are reviewed and revised to meet the changing needs of the organization.
TITLE : RN Care Manager
JOB OVERVIEW : Use of the nursing process in managing populations / diseases / conditions; assessment, planning, implementing, evaluating, screening and rescreening and coordinating care for the purpose of supporting patients and families to live their most healthy life.
AREA OF ASSIGNMENT : Clinic Network
HOURS OF WORK : TypicallyMonday - Friday; Hours may vary to meet department and patient needs.
RESPONSIBLE TO : Clinic Manager
PREREQUISITES :
Current Washington State Registered Nurse license.
BSN preferred
Valid Cardio-Pulmonary Resuscitation Card (CPR) preferred.
Two years of recent clinical experience as an RN working in a clinic / outpatient setting preferred.
Demonstrated knowledge and understanding of information technology.
Completion of the American Academy of Ambulatory Care Nursing (AAACN) Care Coordination and Transition Management (CCTM) Course within three months of hire.
CCTM certification is to be completed within one year of hire unless additional time is needed to meet the eligibility requirements for primary care.
Specialty specific certification is acceptable for specialty clinics and to be completed within one year unless additional time is need to meet the eligibility requirements.
Specialty curriculum hours and content must be equivalent to CCTM.
QUALIFICATIONS :
Ability to communicate effectively, in oral and written form, in the English language.
Demonstrates good communication skills with a diverse population.
Ability to assess, plan, implement and evaluate the needs of the patient.
Understands the importance of adhering to clinical practice guidelines as they relate to disease and population management.
Understands and has the ability to apply principles of population management, disease management and utilization management to the care delivery process.
Demonstrates knowledge of scope and role responsibilities for the roles of the RN, LPN and MA.
Successfully demonstrates the ability to independently establish intravenous access, administer IV medication and conduct blood draw.
Demonstrates ability to act independently.
Demonstrates ability to work collaboratively as a team member.
Demonstrates effective interpersonal skills.
Demonstrates leadership ability and has experience or willingness to lead change.
Demonstrates critical thinking skills, ability to assess, problem solve, and effectively make decisions.
Demonstrates flexibility and manageability of multiple demands.
Has the ability to communicate and work effectively with the physical and emotional development of various age groups.
Ability to maintain professional working relationships with the provider group.
Demonstrates organizational skills that enhance overall nursing staff efficiency.
Understands the components of service delivery to achieve an excellent patient experience.
UNIQUE PHYSICAL / MENTAL DEMANDS, ENVIRONMENT AND WORKING CONDITIONS :
Requires full range of body motion, including handling and lifting patients.
Requires standing and walking for extensive periods of time.
Requires ability to lift and carry items weighing up to 50 pounds in emergency situations.
Requires correct vision and hearing to normal range.
Requires ability to communicate effectively in oral and written fashion.
Requires working under changing conditions.
Requires exposure to communicable diseases or body fluids and other conditions common to the clinical environment.
PERFORMANCE RESPONSIBILITIES :
Generic Job Functions : See generic job description for Clinical Partner.
Essential Responsibilities and Competencies :
Population / Condition Management
Identifies patient populations / conditions requiring care management support.
Assesses patient populations / conditions to identify those resources or other factors needed to achieve the desired outcome for health maintenance or health improvement.
Coordinates healthcare interventions for populations with significant health conditions in which self-management efforts are critical.
Maintains appropriate patient educational materials for populations of patients to meet the needs of patients and families in order to assist with the facilitation of their participation in the plan of care.
Analyzes data related to patient populations / conditions and develops a plan of action. Monitors progress over time and initiatiates changes as needed.
Develops strategies to meet the preventive care and health maintenance measures for populations of patients.
Utilizes the Epic Care Team functionality to become part of the care team for identified patient populations / conditions.
Develops professional relationships with community resources that are used by VMC to care for populations of patients. (, hospice).
Disease Management
Assists in the management of patients with chronic diseases / conditions following established protocols and systems for disease management / conditions in collaboration with providers.
Assesses patient learning needs and has the ability to develop and implement individualized educational or care plans. Reviews, evaluates and revises the plan on an ongoing and timely basis.
Communicates with a multidisciplinary team (physicians, nurses, therapists, social workers, etc.) as needed to assist with disease / conditions management.
Acts as a liaison between clinic, other hospital departments and community resources.
Develops self-management goals and monitors the progress of the goals.
Has the ability to oversee and assist the patient with referral navigation.
Initiates disease / condition specific care conferencing.
Utilizes patient communication strategies, , to involve the patient in developing a plan of care, goals or other specific measures pertinent to their health condition.
Assesses patient activation and readiness for change and uses these to develop self-management goals.
Participates in confidence level assessments or surveys of patients to improve disease management care delivery processes.
Documents all disease / condition management encounters using standardized processes.
Utilization Management
Possesses analytical skills to assess various patient utilization measures, such as ED, Urgent Care and Hospital Visits.
Oversees ED, Urgent Care and Hospital admission utilization rates.
Collaborates with the Leadership team to develop a plan of action to maintain acceptable utilization rates.
Quality
Monitors monthly quality measures, looks for trends, and works collaboratively with the Medical Director and Clinic Manager on process improvement.
Serves as an educational resource and provides consultation to other staff on utilizing evidence based critieria to maintain quality measures.
Participates, as a clinic team member, in Quality Improvement Projects, Initiatives and other clinic activities.
Assists with regulatory readiness and staff compliance (The Joint Commission, DOH, OSHA, etc).
Participates with the quality management of clinical services according to clinic network policies.
Works collaboratively with the MA or LPN Clinic Coordinator, to promote activities that support the overall goals of the clinic related to caring for different populations / conditions of patients.
Education, Training and Competency
Stays abreast of current and updated clinical practices, policies and procedures. Is able to provide clinical expertise in the development of such documents.
Participates in the training of new staff for population management, disease / condition management and utilization management.
Participates in the development and implementation of policies and procedures. Works collaboratively with the leadership team to ensure that the staff comprehend and are compliant with the policies and procedures that relate to population, disease and utilization management.
Acts as an educational resource for the back office team to support the population, disease and utilization management process goals and initiatives.
Maintains job-specific certification.
All other duties as assigned.
Patient Safety
Aware of changes in the National Patient Safety Goals (NPSG) and participates incorporating all NPSG standards into practice.
Triages utilizing approved algorithyms for emergency situations.
Supports the Clinic Manager as an educational resource for error reporting and error management.
Clinic Network RN Care Manager Float Only
Able to travel to multiple clinic locations.
Revised : 2 / 19
Grade : NC27
FLSA : E
CC : Varies
Job Qualifications : PREREQUISITES :
PREREQUISITES :
Current Washington State Registered Nurse license.
BSN preferred
Valid Cardio-Pulmonary Resuscitation Card (CPR) preferred.
Two years of recent clinical experience as an RN working in a clinic / outpatient setting preferred.
Demonstrated knowledge and understanding of information technology.
Completion of the American Academy of Ambulatory Care Nursing (AAACN) Care Coordination and Transition Management (CCTM) Course within three months of hire.
CCTM certification is to be completed within one year of hire unless additional time is needed to meet the eligibility requirements for primary care.
Specialty specific certification is acceptable for specialty clinics and to be completed within one year unless additional time is need to meet the eligibility requirements.
Specialty curriculum hours and content must be equivalent to CCTM.
QUALIFICATIONS :
Ability to communicate effectively, in oral and written form, in the English language.
Demonstrates good communication skills with a diverse population.
Ability to assess, plan, implement and evaluate the needs of the patient.
Understands the importance of adhering to clinical practice guidelines as they relate to disease and population management.
Understands and has the ability to apply principles of population management, disease management and utilization management to the care delivery process.
Demonstrates knowledge of scope and role responsibilities for the roles of the RN, LPN and MA.
Successfully demonstrates the ability to independently establish intravenous access, administer IV medication and conduct blood draw.
Demonstrates ability to act independently.
Demonstrates ability to work collaboratively as a team member.
Demonstrates effective interpersonal skills.
Demonstrates leadership ability and has experience or willingness to lead change.
Demonstrates critical thinking skills, ability to assess, problem solve, and effectively make decisions.
Demonstrates flexibility and manageability of multiple demands.
Has the ability to communicate and work effectively with the physical and emotional development of various age groups.
Ability to maintain professional working relationships with the provider group.
Demonstrates organizational skills that enhance overall nursing staff efficiency.
Understands the components of service delivery to achieve an excellent patient experience.
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