CARE MANAGER-RN
Posted Updated 2
views
Clinical Excellence
FT/ 80 hours per pay
Summary of Position
The RN Care Manager will provide a systematic organization of care with the Physician Practice and will coordinate with other care team members and/or settings. The RN Care Manager will provide high quality, patient centered care management to patients identified as needed by high-risk registries. This will include, but is not limited to developing individualized care plans, care coordination across the continuum, prevention plans, and ongoing monitoring. The RN Care Manager will take a lead role in assuring the care team is informed of the overall care plan, progress and needs.
Nature and Scope
Care Management results from a complex exercise of clinical judgement, occurs through a relationship-based engagement with the care team, and addresses the patient’s identified health care goals. Essential functions include\:
- Documentation of a mutually agreed upon plan of care based on patient’s goals, addressing all significant ongoing health problems and risks.
- Provide ongoing assessment, monitoring, and tracking in E H R. Care will be managed by the use of a registry functionality with interventions triggered by regular review and monitoring.
- Provide proactive care and education outside the routine office visit, for example by phone, Patient Portal, or other access activities.
- Build a trusting, professional relationship with the patient, family, and/or caregivers.
- Utilize self-management and shared decision-making tools.