RN Care Manager.Advanced Primary Care

Description Location: Medina IM/FM/Peds and IMA\n 40 hrs/wk M-F\n A Brief Overview\n Under general supervision of the Supervisor, APC Care Management, the APC Administrator and the Ambulatory Site Clinical Lead provider (MD/DO, APRN, PA), perform as a member of the healthcare team to apply the nursing process when making nursing judgments and decisions specific to assessment, planning, implementation/delivery, and evaluation of patient care, and documenting relevant data and care processes.

The RN Care Manager will facilitate communication between the patients and their Primary Care Providers.

In addition, the RN Care Manager will assist with chronic disease action plans, transitional care management, Advance Directives planning, Annual Wellness Visits, and preventative care utilizing assessment skills both in person and telephonically.

This RN position will be a resource for other team members and critical thinking skills are a must\n What You Will Do\n\nExercise professional nursing judgment appropriate to the level of care needed, and prioritizing patient acuity and workload demands.

The RN Care Manager will function with greater autonomy by consistently demonstrating independent clinical decision making abilities.\nProvide patient care in a manner that demonstrates nursing knowledge and technical competence; recognize significant changes in patient’s condition/situation and take appropriate action.

Communicate with patient/family including but not limited to relaying physician orders and changes in the plan of care, etc.\nAssist and provide guidance to other staff members by acting as a nursing resource; appropriately delegate duties in accordance with appropriate rules/regulations and professional standards of nursing practice; promote team collaboration in meeting the needs of the patient/family.\nWork as a leader in the Advanced Care Model in the ambulatory practice as assigned and work collaboratively with the APC Administrator and Director of APP & UHPS Nursing to drive system wide initiatives and changes\nRN care management integrated into Primary Care office responsible for managing patient’s care across the continuum\nAnalyze sources of data to identify high risk patients and member groups\nManage high risk patients including patients with multiple comorbidities or high risk for readmission\nDevelop longitudinal care planning that includes assessment, planning, implementation and monitoring\nCoordinate continuity of care with patients and families following hospital admission, discharge and ER visits\nAdvocate for patients by assisting in navigation of the health system\nCommunicate to the care team the patient’s goals and progress\nParticipate in quality improvement initiatives\nParticipate on data collection team to evaluate health outcomes, trends, utilization, cost reductions, and programmatic evaluation for areas of improvement\nProvide 1 on 1 office visits for patients to implement care planning\nProvide health and disease education to patients and families, including group education opportunities\nSupport patients in self-management of their disease and behavior modification interventions\nAs a member of the community care team, identifies appropriate resources including specialists, facilities, and external healthcare organization supports to provide an interdisciplinary approach\nCollaborate with office staff in the coordination of individual patient care needs\nSupport and facilitate advanced care planning for patients and their families\nDemonstrate proficiency and act as an expert role model in the performance of patient care\n\n Additional Responsibilities\n\nPerforms other duties as assigned.\nComplies with all policies and standards.\nFor specific duties and responsibilities, refer to documentation provided by the department during orientation.\nMust abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients.

Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.\nQualifications Education Graduate of an accredited school of nursing (Required) and Bachelor's Degree (Preferred) Work Experience3+ years Clinical experience (Required) and 1+ years In the outpatient, ED or urgent care setting (Preferred) and Experience working with Electronic Medical Record application and other computer based patient management tools (Required) Knowledge, Skills, & Abilities Knowledge in navigation of the health care system, including benefits coverage and health treatment protocols (Preferred proficiency) Excellent verbal and written communication skills (Required proficiency) Proven skills in negotiation and collaboration (Required proficiency) Proven time management and organizational skills (Required proficiency) Demonstrated excellence in customer service (Required proficiency) Demonstrated ability to apply concepts, utilize sound judgment and work independently.

(Required proficiency) Good computer skills and ability to utilize Microsoft Outlook, Excel, Word, and Power Point.

(Required proficiency) Licenses and CertificationsRegistered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire) CCM or ACM (Preferred) Physical DemandsStanding Frequently Walking Frequently Sitting Rarely Lifting Frequently 50 lbs Carrying Frequently 50 lbs Pushing Frequently 50 lbs Pulling Frequently 50 lbs Climbing Occasionally 50 lbs Balancing Occasionally Stooping Frequently Kneeling Frequently Crouching Frequently Crawling Occasionally Reaching Frequently Handling Frequently Grasping Frequently Feeling Constantly Talking Constantly Hearing Constantly Repetitive Motions Constantly Eye/Hand/Foot Coordination Constantly Travel Requirements10%