Job Details
We are looking for registered nurses with a passion for providing care to underserved rural patients and their families. Join a dedicated team that is committed to improving the lives of people in rural communities through high-quality primary care. This position will be based in our White House, Tennessee practice.
Job Overview:
As a Registered Nurse Care Manager, you will utilize your clinical skills and knowledge to provide nursing care across the life span to a diverse group of patients and families in a community-based setting utilizing the nursing process to assess, plan, implement, coordinate, and evaluate patient care.
This role will work collaboratively with the primary care provider and all members of the health care team. The RN Care Manager will perform patient assessments/reassessments, identify patient care needs, implement/evaluate the plan of care, and communicate with patients in person and via phone as well as perform specific clinical tasks and procedures in the office setting.
This position is responsible for identification of patients appropriate for Annual Wellness Visits (AWV) and execution of guided processes to complete the visit. The RN care manager will manage and coach high risk, chronic illness patients to promote effective education, self-management support and timely healthcare delivery to achieve optimal quality and financial outcomes. Responsibilities also include coordinating patient care to improve quality of care through the efficient use of resources and acting as an advocate for the individual s healthcare needs.
The Registered Nurse Care Manager is fully responsible for all actions as a licensed professional nurse and is accountable to patients for the quality of care delivered.
Essential Job Functions, Duties, and Responsibilities:
The following list of duties is not intended to be restrictive or all inclusive.
Performs clinical patient care nursing duties within the scope of practice for Registered Nursing maintaining acceptable standards of nursing care, based on community, and standards and policies
Performs screening, triage, assessment and/or patient intake for patient as required by job duties or responsibilities
Utilizes patient medical information, conducts nursing assessments, evaluates current treatment plan, to:
o Prepare for and/or provide care based upon patient visit or encounter needs.
o Identify patients for care management or transitional care management services
o Obtain and evaluate diagnostic results such as vital signs, TB skin testing
o Deliver and/or evaluate patient/family teaching or skill validation
Performs therapeutic point of care diagnostic testing as ordered for patients
Performs nursing procedures utilizing evidence-based practice guidelines or clinical standards
Focuses clinic efforts on patient satisfaction, clinical quality measures, HEDIS, and meaningful use standards
Provides high intensity engagement with patient and family and serves as a patient advocate
Follows Annual Wellness Visit protocols and standing orders including completion of preventive services as appropriate
Addresses open quality gaps with patients and works collaboratively towards closure
Addresses advanced care planning including treatment goals and advance directives
Records, reports, and interprets nursing services and patient s responses
Utilizes incoming reports of emergency room utilization, hospital/facility discharges and medical information to initiate transitional care management activities and plan of care
Follows up on Registry patients (Abnormal Paps, Mammograms, Colorectal, and Lab Results) by determining appropriate next actions and contacting patient to provide information and referral/scheduling information as necessary.
Track patients with a history of abnormal registry results to ensure compliance with recommended actions
Performs chronic care and disease management activities for complex patients and monitors effectiveness using outcome reports and dashboards
Interacts professionally in person and telephonically with patient/family to develop, inform, educate, counsel to plan of care
Communicates, coordinates, and consults with members of the health team to eliminate barriers to care delivery and meet individual patient s healthcare needs
Maintains accurate and timely documentation of the patient s care in the EMR
Maintains EMR databases on care managed populations
Complies with federal, state, and local regulatory requirements and participates in the preparation and conduction of clinic or program regulatory audits
Assists in the development and implementation of quality, cost-effective, efficient systems, and protocols for standardizing processes of patient care at clinics
Subject matter expert for patient education, assessment, interpretation, and documentation of patient care and testing.
Assists as needed with other clinical duties such as prior authorizations, referrals, patient messages, prescription refills
Minimum Qualifications:
Education: Associate Degree in Nursing. Baccalaureate degree preferred.
Current CPR /BLS
Experience: Minimum of 2-3 years experience as a registered nurse
Experience in primary care, chronic care/disease management, or care coordination preferred
License: Current nursing licensure in good standing in TN or compact license
Must have:
Knowledge: Knowledge of nursing process, scope of practice and standards of care
Knowledge of primary health care and the social determinants of health
Knowledge of concepts of health assessment, health promotion, disease prevention, chronic disease management, care coordination and transitions of care
Health coaching or motivational interviewing
Knowledge and awareness related to cultural competence
In-depth knowledge of health assessment and interventions in the family
practice context
Skills & Abilities: Ability to work independently and be self-directed
Ability to collaborate and work well with other healthcare professionals
Ability to delegate care appropriately
Ability to be an effective change agent
Effective organizational, critical thinking, problem-solving and decision-making skills
Excellent communication skills and ability to adapt communication styles
to meet the needs of patients, healthcare team members and community
partners
Proficient in EMR documentation and computer/technology savvy