RN, Care Manager (Full-Time)

HHHN Mission To provide the best health care, and access to that care, for everyone in our communities. HHHN Vision To pioneer an innovative, sustainable and community-focused health system through comprehensive primary care and diverse partnerships. Proposed Schedule- Monday-Friday 8-4:30 Position Summary The RN Care Manager is an integral part of the patient’s care team, enhancing primary care and providing an array of services to the patients of the network and support to the primary/specialty care settings. These services include but are not limited to: education, coordination, coaching, transfer of self-management skills, and addressing barriers (including socio-economic). Guidance will be provided to the patients and families for the purpose of improving the health of our populations, improving the quality of care provided and decreasing overall costs. Integrated comprehensive patient-centered care plans will be developed alongside the patient, resulting in improved patient outcomes. Care management activities will occur onsite in health centers, via telehealth, and/or occasionally at the patients’ home, hospital or other community setting. Essential Duties and Responsibilities: • Provide outreach, information, guidance, and education to the patient and/or family, primary care providers and other members of the care team for appropriate healthcare utilization, chronic disease (e.g. diabetes, hypertension) self-management skills, effective care transitions, assessment and elimination of barriers, including socio-economic barriers, promoting wellness and preventative care measures and enhanced patient-provider communication • Develop individualized, goal-oriented, patient-centered care plans that promote positive outcomes and address physical health, mental health and socio-economic barrier. • Maintain an ongoing responsibility for assigned caseload by prioritizing referrals and activities according to intensity, needs and required follow-up • Provide appropriate teaching, information, instruction and referral services to patients managing various chronic health conditions on-site at the health center, via telehealth, and/or in a home setting • Assess, identify, and close clinical and non-clinical gaps in patient care • Collaborate with health center care team to review results from bloodwork and other tests and provide patient education and follow-up as needed. • Demonstrate knowledge in medical care; such as diagnostic procedures, medication, symptoms, and other treatment-related therapies • Support non-clinical care management team members by providing supplemental patient education through patient outreach • Conduct regular follow-ups with patients to evaluate progress, promote continuity of care, and ensure improved health outcomes • Complete annual care management competencies and any other relevant competencies/trainings as needed • Competent in coaching patients/caregivers on how to obtain a blood glucose level for the purpose of self-management and when to report concerns to health center care team • Competent in coaching patients/caregivers on how to properly self-administer insulin via pen cartridge, and when to report concerns to the health center care team • Work closely with the care management team and build efficient and effective relationships among care team members, including outreach to external organizations that support a positive outcome for patients • Recognize the patient as a contributing member of the clinical team • Serve on network-wide initiatives that support the mission, vision and core values. • Provide any other services as directed by HHHN to ensure proper care and treatment to the patient and/or families. • Maintain accurate and timely documentation within multiple concurrent platforms Qualifications: The requirements listed below are representative of the knowledge, skill and ability to perform the essential functions: • Active, unrestricted RN license in the state of practice • Current BLS certification • Applied professional experience in case (care) management and/or social work preferred. • Experience working in fields of Health care, behavioral/mental health, substance/alcohol abuse preferred • Must have a valid driver license and be able to travel throughout the Network • Must have strong verbal and written communication skills • Proficient computer competencies including Microsoft applications, electronic medical records and related databases • Must be well organized and can effectively manage multiple cases and projects • Must be self-directed, detail-oriented and motivated • Must be able to work independently as well as collaborate and communicate effectively with colleagues, supervisors, service delivery partners, other health care professionals and coworkers to build and maintain effective dynamic professional team relationships