RN Care Manager Value Based Care Institute Population Health

Overview:

The VBCI Population Health RN Care Manager plays a crucial role in applying value-based care principles to provide top-quality, patient-centric healthcare services that improve health outcomes for a wide range of individuals. Responsible for assessing, planning, implementing, coordinating, and evaluating available services to enhance the overall health status of patients. Tracks and assesses patient care advancement towards set objectives, offering suggestions and utilizing appropriate resources to enhance the efficiency and success of care plans. Ensures smooth transitions between different clinical and non-clinical environments throughout the continuum of care. Offers support to VBCI Population Health Programs, including Complex Care Management & Transitions of Care for Cone Health System and THN ACO populations.

Responsibilities:

Case management and care coordination involve working with diverse teams to create, execute, and oversee personalized care strategies for individuals, guaranteeing inclusive and complete assistance. Serve as a connection between patients, their families, and medical professionals to maintain seamless care delivery throughout different environments.

Patient Involvement: Providing education and empowerment to patients and their families regarding health issues, treatment choices, and ways to take care of themselves. Using motivational interviewing and teach-back approaches for better understanding.

Assessment and Monitoring: Engage in comprehensive health evaluations, pinpoint obstacles to treatment, and oversee patient advancements to enhance results, prevent hospitalizations, rehospitalizations, visits to the emergency department, and/or worsening conditions. The healthcare provider must exhibit the capacity to preemptively evaluate and foresee the requirements of patients, identifying initial indications of potential issues or decline in their health. This involves utilizing analytical thinking abilities to oversee shifts in health conditions and promptly stepping in to guarantee ideal patient results. Consistently assess and modify treatment strategies according to patient advancements and results, utilizing information to guide choices.

Quality Assessment: Aid in managing HEDIS criteria concerning proactive healthcare, ongoing condition supervision, and seamless patient support to meet quality standards.

Close the Care Gap: Recognize and target areas where patients lack necessary care, ensuring they receive essential screenings, vaccinations, and follow-up visits to enhance their health results.

Resource Management involves guiding patients to community resources, support services, and specialized care when necessary.

Data Management: Make use of electronic health records (EHR) for monitoring patient progress, recording healthcare interventions, and meeting regulatory requirements efficiently.

Participate actively in quality enhancement programs concentrating on addressing gaps in care, enhancing HEDIS metrics, and boosting overall patient contentment, thereby aiding in the establishment of superior methodologies to enhance patient results. Engage in initiatives aimed at narrowing care disparities, elevating HEDIS achievements, and fostering general patient gratification to foster the advancement of optimal practices and enrich patient welfare. Get involved in projects dedicated to bridging care deficiencies, elevating HEDIS performance levels, and enhancing overall patient happiness to play a role in refining best practices and advancing patient results. Take part in quality enhancement efforts targeted at closing care gaps, enhancing HEDIS metrics, and elevating overall patient fulfillment, which are essential for establishing superior strategies to enhance patient outcomes. Contribute to quality enhancement endeavors focused on closing care gaps, improving HEDIS performance, and enhancing overall patient satisfaction levels to support the creation of best practices and enhance patient well-being. Get engaged in quality improvement projects concentrated on closing care gaps, boosting HEDIS performance, and enhancing overall patient satisfaction to aid in the formulation of effective techniques that promote better patient outcomes. Engage in initiatives that focus on improving quality by closing gaps in care, enhancing HEDIS performance, and increasing overall patient satisfaction levels to help develop best practices and improve patient results. Participate actively in quality improvement initiatives that are centered on closing care gaps, improving HEDIS performance, and enhancing overall patient satisfaction, aiming to contribute to the evolution of optimal practices and enhance patient outcomes. Take part in quality improvement programs that target the closure of care gaps, the improvement of HEDIS metrics, and the enhancement of overall patient satisfaction, contributing to the development of best practices and the improvement of patient outcomes. Participate in initiatives focused on quality improvement, specifically on closing gaps in care, improving HEDIS performance, and enhancing overall patient satisfaction levels to facilitate the creation of best practices and enhance patient well-being.

Advocacy involves acting as a patient representative, guaranteeing that patient beliefs and choices are considered in the development of care plans and choices.

Utilize data and analytics to assess quality measures, patient results, and coordination of care activities for both internal and external audiences.

Gain specialized clinical knowledge in specific areas of practice and establish yourself as a valuable asset for managing patient populations with conditions such as COPD, diabetes, heart failure, sepsis, end-stage renal disease, sickle cell anemia, hypertension, among others. Recognize and address possible health emergencies proactively, delivering interventions promptly to minimize the need for hospital stays or visits to the emergency department.

Responsible for fulfilling all position-related duties and adhering to all company policies and guidelines. The details included in this description do not cover every possible task but highlight key requirements essential for effective job performance. Any additional proficiencies and qualifications specified in a department-specific onboarding will also be crucial for excelling in the role associated with that position.

Qualifications:

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/REGISTRY/LISTING:REQUIRED

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.