Registered Nurse Care Manager

Job DescriptionSun River Health provides the highest quality comprehensive primary, preventative and behavioral health services to all who see it, regardless of insurance status and ability to pay, especially for the underserved and vulnerable. Sun River Health is a Federally Qualified Non-Profit Health Center serving communities in Suffolk, Rockland, Orange, Dutchess, Ulster, Sullivan, Columbia and Westchester County. Sun River Health is currently seeking a full-time Registered Nurse/Care Manager to join our team at our Poughkeepsie - Washington Street site.Job Type: Full-timePay Range: $45.00- $50.33 hourly$2,700 Sign-On Bonus – Terms and Conditions ApplySummary:The RN Care Manager is responsible for coordinating screenings, assessments, care planning, and providing care management services to patients identified as having complex chronic care needs. Acts as a connector between patient needs and the resources provided by the care management program. The RN care manager will promote self-care management and assist with access to care. The RN care manager works with patients through direct face to face patient contact or telephonically. Provides guidance and leadership in the care management program to those in the healthcare organization as well as ensuring the patients receive the best possible care.Responsibilities:Identifies, tracks and manages care for designated risk stratified patientsConducts initial care coordination screening eligibility and performs comprehensive risk assessmentWorks directly with patients/family members and providers to develop and implement an individualized and integrated patient care plan for patientPromotes clear communication amongst a care team including treating clinicians by ensuring awareness regarding patient care plansAdapts practice to meet individual patient circumstances considering level of health literacy and cultural and linguistic differences, ensuring that effective communication is achieved, particularly where there may be barriers to understandingOngoing clinical assessment, monitoring and follow up for designated risk stratified patientsAssessment and early identification of decompensating disease with appropriate intervention and managementAssesses psychological needs and ability to benefit from community resources and referrals to outside agencies/programs when appropriatePerforms medication review, reconciliation and coordination with a licensed prescriber for medication adjustment where indicatedProvides organizational approved patient education materials including but not limited to health promotion and disease managementAssists in the maintenance of the patient's health, wellness and prevention of secondary disease complications by providing education, counseling and supportHandles protective health information in a manner consistent with the Health Insurance Portability and Accountability Act (HIPAA)Collaborates with interdisciplinary teams to assess patient needs and deliver care to identified population upon discharge from varying clinical settings. Supports care transitions by coordination of activities needed to prevent or reduce utilization of emergency services or hospitalizationsEnsures the ongoing and timely reassessment and follow-up of all care plans on a scheduled basis ensuring timely updating and documentation of patient progress toward agreed upon goalsPromotes the coordination of relevant health and social care services to remove barriers related to social determinants of healthRequirements:Minimum Education Required: Bachelor of Science Nursing (BSN)Minimum Work-Related Experience: 0-1 yearPreferred Work-Related Experience: 2-4 yearsBilingual Spanish speaking preferredMinimum Licensure:Minimum Requirement: NYS RN Licensed and CPR/Infection Control CertificationAbout Sun River HealthSun River Health has a rich history of providing quality, affordable health care to communities in need. Founded in the early 1970s by four African American women in Peekskill, New York, the organization was established to address the lack of accessible health services in their community. With the help of a small federal grant, the first Sun River Health site opened its doors in 1975. Over the years, Sun River Health has grown into a comprehensive Federally Qualified Health Center (FQHC) system with over 45 locations, serving more than 250,000 patients across Hudson Valley, New York City and Long Island. Our exceptional primary care practitioners, specialists and support staff are dedicated to delivering high-quality care to all individuals, regardless of their ability to pay. In December 2018, Sun River Health expanded its reach by merging with Brightpoint Health, an FQHC network offering integrated medical, behavioral and social support services in New York City. This merger allowed us to enhance our services and continue our mission under the unified name of Sun River Health.Our CultureAt Sun River Health, we believe in fostering a culture of wellness, inclusivity and recognition. Our Workforce Wellness Program promotes staff wellness through ongoing challenges and activities, encouraging participation and rewarding engagement. We celebrate our staff's dedication and person-centered spirit through the Planetree Recognition Awards, which honor innovation, leadership and community spirit. We are committed to creating a supportive and collaborative work environment where all team members can thrive. Our values of respect, integrity and excellence guide our interactions with patients and colleagues alike, ensuring that everyone receives the care and support they deserve.BenefitsAt Sun River Health, we are committed to building a personal relationship with our team and supporting you in every way we can. We offer competitive compensation and a comprehensive benefits package for you and your family, including:Medical, Dental and Vision Insurance: Comprehensive health coverage to ensure you and your family stay healthy.Life and Disability Coverage: Financial protection for you and your loved ones in case of unforeseen circumstances.Retirement Savings Plan: Plan for your future with our retirement savings options.Commuter and Transit Benefits: Assistance with your daily commute to make your journey to work easier.Employee Assistance Program (EAP): Access to confidential support and resources for personal and work-related issues.Employee Discount Program: Enjoy discounts on various products and services as a valued member of our team.Provider Incentive Compensation Program: Quality & Productivity.Provider Professional License, Certification and DEA Fees Reimbursement.Professional Development, Education and Loan Assistance Benefit ProgramsSun River Health is committed in fostering continued growth, education, and professional advancement across its organization. Through a range of development opportunities and loan repayment programs employees are supported at every stage of their careers.Eligible employees may have the opportunity to participate in federal and state loan repayment or loan forgiveness programs, including those administered by the Health Resources and Services Administration (HRSA) and the National Health Service Corps (NHSC) with support provided throughout the application process.In addition, Sun River Health offers a Tuition Reimbursement Program for eligible employees that supports job-related coursework completed through accredited institutions, helping employees continue building their skills and advancing their careers.Why Join Sun River Health?Mission-Driven Work: Be part of a proud network of care that offers high-quality health and social support services to communities in need.Professional Growth: We provide opportunities for career advancement and professional development.Supportive Environment: Our culture promotes wellness, inclusivity, and recognition, ensuring a supportive and collaborative work environment.Community Impact: Make a difference in the lives of individuals and families by providing quality, affordable health care.Join us at Sun River Health and be part of an award-winning network of care that has been serving our communities since 1975. We are always looking for skilled and dedicated professionals to join our team and help us continue our mission of providing quality health care to all.