Registered Nurse (RN) Nights

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.

Responsibilities:

• By collaborating with teams from different disciplines, case managers can develop, implement, and oversee individualized care plans for patients, ensuring they receive comprehensive and holistic care. Acting as a mediator between patients, families, and healthcare providers is crucial for ensuring seamless care coordination across various settings.
• Fostering Patient Engagement: Educate and empower patients and their families about medical conditions, treatment options, and self-care strategies. Utilize motivational interviewing techniques and teach-back methods to promote active participation in healthcare.
• Undertake comprehensive health screenings, identify obstacles to treatment, and monitor patient advancements to optimize results, avert hospital admissions, readmissions, emergency room visits, or health setbacks.
• Demonstrating proactive assessment skills, the nurse should be able to anticipate and recognize patients' needs, identifying early signs of potential complications or deterioration in their health.
• This requires the utilization of critical thinking skills to monitor changes in health status and intervening effectively to guarantee optimal patient outcomes.
• Continuously evaluate and adjust care plans based on patient progress and outcomes, utilizing data to guide decisions effectively.
• Benchmark Adherence: Aid in addressing HEDIS benchmarks connected to preventative care initiatives, the management of chronic diseases, and the facilitation of effective care coordination to ensure compliance with quality standards.
• Closing the Healthcare Discrepancy: Identify and resolve gaps in care for patients, assisting in recommended screenings, vaccinations, and follow-up visits to improve their holistic health results.
• Resource Management: Support patients in accessing and linking with community resources, support services, and specialized medical attention based on their needs.
• Data Management: Use electronic health records (EHR) for monitoring patient outcomes, documenting care interventions, and meeting regulatory standards.
• Participate in quality enhancement programs that prioritize the closure of care gaps, augmented HEDIS performance, and enhanced patient gratification overall, contributing to the evolution of superior practices and better patient outcomes.
• Advocacy plays a crucial role in ensuring that patient preferences and values are given importance and are integrated into the process of care planning and decision-making.
• Leverage data and analytics to evaluate quality metrics, patient outcomes, and care coordination efforts for internal and external viewers.
• Develop expertise in specific medical fields or long-standing ailments to be acknowledged as a pivotal figure in care administration, emphasizing the supervision of particular patient groups like those affected by chronic obstructive pulmonary disease, diabetes, heart failure, sepsis, end-stage renal disease, sickle cell anemia, hypertension, and more.
• Responsible for meeting job-specific requirements and following all company policies and procedures.
• The information provided in this profile is not exhaustive in its scope.
• They epitomize crucial elements needed for job proficiency.
• The competencies and skills articulated in a department-specific orientation play a critical role in achieving success in the job associated with 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.