RN Care Manager Transitions of Care Value Based Care Institute

The VBCI Population Health RN Care Manager will prioritize value-based care principles, focusing on delivering high-quality, patient-centered services that enhance health outcomes for our diverse population. The RN Care Manager assesses, plans, implements, coordinates, monitors, and evaluates all options and services with the goal of optimizing the patient's health status. Monitors patient care progress toward goals; makes recommendations and/or utilizes appropriate resources to optimize effective, efficient care progression and care plan goal achievement. Ensures seamless transitions between various clinical and non-clinical settings across the care continuum. Supports the VBCI Population Health Programs; Complex Care Management & Transitions of Care for Cone Health System and THN ACO populations.

Essential Job Function

• Case Management/Care Coordination: Collaborate with interdisciplinary teams to develop, implement, and manage individualized care plans for patients, ensuring comprehensive, holistic support.
• Act as a liaison between patients, families, and healthcare providers to ensure continuity of care across settings.
• Patient Engagement: Educate and empower patients and their families about health conditions, treatment options, and self-management strategies.
• Leveraging motivational interview techniques and teach back methods.
• Assessment and Monitoring: Conduct thorough health assessments, identify barriers to care, and monitor patient progress to optimize outcomes, prevent admissions readmissions, emergency department visits and/or exacerbations.
• The nurse should demonstrate the ability to proactively assess and anticipate patients' needs, recognizing early signs of potential complications or deterioration in their condition.
• This includes employing critical thinking skills to monitor changes in health status and effectively intervening to ensure optimal patient outcomes.
• Regularly review and adjust care plans based on patient progress and outcomes, utilizing data to inform decisions.
• Quality Measurement: Assist with addressing HEDIS measures related to preventive care, chronic disease management, and care coordination, ensuring compliance with quality metrics.
• Care Gap Closure: Identify and address care gaps for patients, facilitating necessary screenings, vaccinations, and follow-up appointments to improve overall health outcomes.
• Resource Management: Navigate and connect patients with community resources, support services, and specialty care as needed.
• Data Management: Utilize electronic health records (EHR) to track patient outcomes, document care activities, and ensure compliance with regulatory standards.
• Quality Improvement: Participate in quality improvement initiatives focused on care gap closure, HEDIS performance, and overall patient satisfaction, contributing to the development of best practices and improve patient outcomes.
• Advocacy: Serve as a patient advocate, ensuring that patient preferences and values are incorporated into care planning and decision-making processes.
• Reporting and Analysis: Leverage data and analytics to evaluate quality metrics, patient outcomes, and care coordination efforts for internal and external stakeholders.
• Clinical expertise: Develop clinical expertise in specialty areas and/or chronic conditions and be recognized as a care management resource for population management (ie COPD, Diabetes, HF, Sepsis, ESRD, Sickle Cell Anemia, HTN, etc).
• Identify and respond to potential health crises, providing timely interventions to prevent hospitalizations and/or emergency department visits.
• Accountable for satisfying all job specific obligations and complying with all organization policies and procedures.
• The specific statements in this profile are not intended to be all-inclusive.
• They represent typical elements considered necessary to successfully perform the job.
• Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.

Education

• Required: Graduate from Specialty Training Program - Nursing Preferred: Bachelor of Science in Nursing (BSN).

Experience

• Required: Minimum of two years? experience as an outpatient RN Care Manager managing adult patients with complex medical needs and multiple chronic conditions -or- a minimum of 5 years? experience as a Registered Nurse in an acute care and/or home care setting managing adults. Preferred: Five plus years? experience in Care Management with a Certification in a specialty area. A demonstrated history of providing care management services to high-risk adult and geriatric populations in an outpatient setting.

Licensure/Certification/Listing

• Required: Registered Nurse (RN) License: Must have an active RN license in the state where you will be practicing. Preferred: RN licensure & Certified Case Manager (CCM): Offered by the Commission for Case Manager Certification. For this position, AHA Health Care Provider BLS (CPR) is optional at all Cone Campuses except Behavioral Health Hospital where it is required.

Required

Preferred

Job Industries

• Other