RN Care Manager Value Based Care Institute Post Acute Care

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.

Essential Job Function

• Collaborating with various professionals is vital in Case Management/Care Coordination to develop, execute, and manage customized care plans for patients, ensuring comprehensive and holistic assistance.
• Encouraging patient education: Empower patients and their families with knowledge about health conditions, treatment options, and self-care strategies. Utilize motivational communication techniques and verify comprehension through teaching and feedback mechanisms.
• Assessment and Monitoring: The key responsibilities for nurses include conducting thorough health assessments, identifying obstacles to care, and monitoring patient progress to improve outcomes, prevent hospital admissions or readmissions, emergency visits, and exacerbations. Nurses should exhibit adeptness in anticipating and meeting patients' needs, identifying initial signs of potential complications or deterioration in their health. This involves employing critical thinking skills to track changes in health status and intervening promptly to ensure the best patient results. It is vital to frequently reassess and adapt care plans according to patient advancements and results, utilizing data for decision-making.
• Barometers of Excellence: Assist with managing HEDIS standards focused on preventative healthcare, chronic disease oversight, and care synchronization, ensuring conformity with quality indicators.
• Care Gap Elimination: Recognize and rectify care deficiencies for patients by organizing essential screenings, vaccinations, and follow-up appointments to enhance overall health outcomes.
• Aid patients in connecting with community resources, support services, and specialty care based on their needs.
• Deploy electronic health records (EHR) to monitor patient outcomes, document care activities, and ensure compliance with regulatory standards for effective data management.
• Participate in initiatives focusing on boosting care quality by narrowing care gaps, raising HEDIS effectiveness, and improving overall patient contentment, which contributes to the establishment of best practices and enhancing patient outcomes.
• Advocacy involves advocating for patients by ensuring that their preferences and values are included in the planning and decision-making processes regarding their care.
• Harness the power of data and analytics to evaluate quality benchmarks, patient results, and the efficacy of care coordination programs for both internal and external stakeholders.
• Clinical expertise: Acquire in-depth knowledge in particular medical specialties or chronic diseases, positioning oneself as an indispensable figure in managing the health of distinct patient populations (e.g., patients with COPD, Diabetes, Heart Failure, Sepsis, End-Stage Renal Disease, Sickle Cell Anemia, Hypertension, etc.). Acknowledge and respond to potential health emergencies by offering prompt interventions to prevent hospitalizations or emergency department visits.
• Expected to fulfill all job-related responsibilities and conform to all company policies and guidelines. The specific details in this profile may not cover all potential duties.
• These factors are seen as the requisite elements for the successful execution of the task.
• Essential competencies and skills detailed in the orientation for a particular department are deemed integral to the job performance associated with the role.

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.