RN Care Manager Value Based Care Institute Complex Care Management

The VBCI Population Health RN Care Manager places value-based care principles at the forefront, concentrating on dispensing top-quality, patient-oriented services that amplify health outcomes for a diverse community. Their tasks encompass evaluating, strategizing, executing, coordinating, supervising, and evaluating all choices and services with the aim of enhancing the patients health condition. They keep an eye on the progress of patient care towards objectives, offer recommendations, and employ suitable resources to boost efficient and effective care progression and the accomplishment of care plan aims. Their role also involves ensuring seamless shifts between different clinical and non-clinical environments along the care continuum. They offer support for the VBCI Population Health Programs such as Complex Care Management & Transitions of Care for Cone Health System and THN ACO populations.

Essential Job Function

• The focus of Case Management/Care Coordination is on teaming up with interdisciplinary groups to establish, execute, and oversee unique care blueprints for patients, ensuring inclusive and holistic backing.
• Help in maintaining the flow of information among patients, families, and healthcare providers to ensure cohesive care delivery.
• Fostering patient empowerment: Educate and support patients in making informed decisions regarding their health conditions, treatment alternatives, and self-care routines.
• Harnessing motivational interview tactics and the teach-back technique for effective communication.
• Utilize thorough health assessments, recognize impediments to treatment, and supervise patient development to maximize effectiveness, decrease hospitalizations, readmissions, ER trips, and exacerbations.
• Nurses are encouraged to display the capacity to actively evaluate and predict the needs of patients, recognizing initial signs of possible complications or worsening of their state of health.
• This encompasses the application of critical thinking skills to oversee fluctuations in health status and intervene proactively to enhance patient outcomes.
• Regularly reassess and tweak care plans based on patient development and results, utilizing data for decision-making purposes.
• Support in dealing with HEDIS criteria linked to preventative measures, the administration of persistent illnesses, and the organization of care to adhere to quality guidelines.
• Care Gap Resolution: Detecting and tackling deficiencies in patient care by facilitating crucial screenings, vaccinations, and follow-up consultations to boost health outcomes effectively.
• Help patients access community resources, support services, and specialized care based on their needs.
• Implement data management strategies through the integration of electronic health records (EHR) for monitoring patient outcomes, documenting care interventions, and ensuring compliance with relevant regulations.
• Join efforts to enhance quality by focusing on closing care gaps, enhancing HEDIS performance, and elevating overall patient satisfaction, actively working towards the creation of optimal approaches to enhance patient outcomes.
• Patient advocacy involves making sure that patient preferences and values are taken into account during the planning and decision-making stages of care.
• Employing data-driven techniques and analytical methods to review quality benchmarks, patient consequences, and the efficiency of care coordination endeavors supports the production of thorough assessments for a diverse audience.
• Foster advanced clinical skills in specialty domains and chronic ailments to be identified as a crucial care management consultant for population health, encompassing conditions like COPD, Diabetes, Heart Failure, Sepsis, End-Stage Renal Disease, Sickle Cell Anemia, Hypertension, among others.
• Identify and manage potential health crises through swift interventions to mitigate the need for hospital stays or emergency room visits.
• Obligated to complete all job-specific responsibilities and adhere to the rules and regulations set by the organization.
• The specific statements in this profile are not intended to be all-inclusive.
• These elements embody the crucial aspects essential for carrying out the job proficiently.
• 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

• Candidates must have successfully graduated from a specialty training program in nursing, with a Bachelor of Science in Nursing degree being highly desirable.

Experience

• To qualify for this position, candidates must possess a minimum of two years of experience working as an outpatient RN Care Manager, overseeing 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 or home care capacity caring for adults. Additional desired qualifications include five or more years of experience in Care Management with a specialty Certification, as well as a documented history of delivering care management services to high-risk adult and geriatric populations in an outpatient setting.

Licensure/Certification/Listing

• The possession of an active RN license in the state of practice is mandatory. Candidates are encouraged to have both RN licensure and Certified Case Manager (CCM) certification. While AHA Health Care Provider BLS (CPR) is not compulsory at most Cone Campuses, it is a requirement at the Behavioral Health Hospital.