RN Care Manager Advanced Primary Care Geauga

Job Description – RN Care Manager Advanced Primary Care Geauga (26000610) A Brief Overview Under general supervision of the Supervisor, APC Care Management, the APC Administrator and the Ambulatory Site Clinical Lead provider (MD/DO, APRN, PA), the RN Care Manager performs 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 facilitates communication between the patients and their Primary Care Providers and assists 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 is a resource for other team members and requires critical thinking skills. What You Will Do Exercise professional nursing judgment appropriate to the level of care needed, prioritizing patient acuity and workload demands. The RN Care Manager functions with greater autonomy by consistently demonstrating independent clinical decision‑making abilities. Provide patient care that demonstrates nursing knowledge and technical competence; recognize significant changes in patients’ condition/situation and take appropriate action. Communicate with patients/families, including relaying physician orders and changes in the plan of care. Assist and provide guidance to other staff members by acting as a nursing resource; appropriately delegate duties in accordance with rules, regulations and professional standards of nursing practice; promote team collaboration in meeting the needs of the patient/family. Work as a leader in the Advanced Care Model in ambulatory practice and collaborate with the APC Administrator and Director of APP & UHPS Nursing to drive system‑wide initiatives and changes. Integrate RN care management into the Primary Care office responsible for managing patients’ care across the continuum. Analyze sources of data to identify high‑risk patients and member groups. Manage high‑risk patients, including those with multiple comorbidities or at high risk for readmission. Develop longitudinal care planning that includes assessment, planning, implementation, and monitoring. Coordinate continuity of care with patients and families following hospital admission, discharge, and ER visits. Advocate for patients by assisting in navigation of the health system. Communicate the patient’s goals and progress to the care team. Participate in quality improvement initiatives. Participate in data collection to evaluate health outcomes, trends, utilization, cost reductions, and programmatic evaluation for areas of improvement. Provide one‑on‑one office visits for patients to implement care planning. Provide health and disease education to patients and families, including group education opportunities. Support patients in self‑management of their disease and behavior modification interventions. As a member of the community care team, identify appropriate resources—including specialists, facilities, and external healthcare organization supports—to provide an interdisciplinary approach. Collaborate with office staff in the coordination of individual patient care needs. Support and facilitate advanced care planning for patients and their families. Demonstrate proficiency and act as an expert role model in the performance of patient care. Additional Responsibilities Perform other duties as assigned. Comply with all policies and standards. Refer to documentation provided by the department during orientation for specific duties and responsibilities. Abide by all requirements to safely and securely maintain Protected Health Information (PHI) for patients. Annual training, the UH Code of Conduct and UH policies and procedures address appropriate use of PHI in the workplace. Education Graduate of an accredited school of nursing (Required). Bachelor’s Degree (Preferred). Work Experience 3+ years of clinical experience (Required). 1+ year in the outpatient, ED, or urgent care setting (Preferred). Experience working with an Electronic Medical Record application and other computer‑based patient management tools (Required). Knowledge, Skills, & Abilities Knowledge of 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 use Microsoft Outlook, Excel, Word, and PowerPoint (Required proficiency). Licenses and Certifications Registered Nurse (RN), Ohio and/or Multi‑State Compact License (Required upon hire). CCM or ACM (Preferred). Physical Demands Standing frequently. Walking frequently. Sitting rarely. Lifting frequently up to 50 lbs. Carrying frequently up to 50 lbs. Pushing frequently up to 50 lbs. Pulling frequently up to 50 lbs. Climbing occasionally up to 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 Requirements 10 %. #J-18808-Ljbffr University Hospitals