RN Care Manager: VBCI Population Health

Overview:

The VBCI Population Health RN Care Manager's primary focus lies in prioritizing the ideals of value-based care, emphasizing the delivery of top-notch, patient-focused services that improve health outcomes for a diverse population. This individual is tasked with evaluating, designing, executing, coordinating, overseeing, and appraising all potential options and services with the specific objective of optimizing the health status of each patient. Supervises the progress of patient care towards predetermined goals, providing suggestions and leveraging suitable resources to boost the efficiency and success of care plans. Ensures smooth handovers between different clinical and non-clinical environments across the care continuum. Provides assistance for VBCI Population Health Programs like Complex Care Management & Transitions of Care for Cone Health System and THN ACO populations.

Responsibilities:

Case Management/Care Coordination: Engage in teamwork with various professionals to devise, execute, and oversee customized care schedules for patients, offering thorough and well-rounded aid. Function as a communication bridge among patients, their relatives, and healthcare experts to sustain consistent care provision across various platforms.

Promoting Patient Engagement: Offering information and support to patients and their families on health conditions, available treatments, and how to manage their well-being effectively. Utilizing motivational interview skills and teach-back techniques for enhanced communication.

Assessment and Monitoring: Conduct thorough health assessments, identify barriers to care, and monitor patient progress to optimize outcomes, prevent admissions readmissions, emergency department visits and/or exacerbations. The nurse should demonstrate the ability to proactively assess and anticipate patients' needs, recognizing early signs of potential complications or deterioration in their condition. This includes employing critical thinking skills to monitor changes in health status and effectively intervening to ensure optimal patient outcomes. Regularly review and adjust care plans based on patient progress and outcomes, utilizing data to inform decisions.

Measurement of Excellence: Support in adhering to quality benchmarks by focusing on HEDIS indicators for preventative services, long-term illness oversight, and efficient care collaboration.

Bridging Care Disparities: Pinpoint and rectify the discrepancies in healthcare for patients, aiding in providing essential screenings, vaccinations, and follow-up consultations to enhance their overall well-being.

Help patients access community resources, support services, and specialized care through Resource Management.

Data Management: Employ electronic health records (EHR) to oversee patient results, log care procedures, and uphold adherence to industry regulations.

Quality Improvement: Participate in quality improvement initiatives focused on care gap closure, HEDIS performance, and overall patient satisfaction, contributing to the development of best practices and improve patient outcomes.

Advocacy entails supporting patients to have their preferences and values reflected in the planning and decision-making aspects of care.

Evaluate quality indicators, patient end results, and the effectiveness of care coordination using data analysis and reporting techniques.

Acquire advanced clinical skills in specialized fields or chronic illnesses and position yourself as a key figure in care coordination for managing populations with conditions like chronic obstructive pulmonary disease, diabetes, congestive heart failure, sepsis, end-stage renal disease, sickle cell disease, hypertension, and more. Detect and address potential health emergencies swiftly, offering timely interventions to avert hospitalizations or trips to the emergency room.

Tasks include meeting all job-specific requirements and following established organization protocols. The information provided in this overview is not exhaustive but showcases fundamental aspects needed for successful job execution. Further competencies and proficiencies identified in specialized departmental training will also be vital for carrying out duties related to that particular role.

Qualifications:

EDUCATION:

Required:

• Graduate from Specialty Training Program - Nursing

Preferred:

Bachelor of Science in Nursing (BSN).

EXPERIENCE:

Required:

• Minimum of two year's experience as an outpatient RN Care Manager managing adult patients with complex medical needs and multiple chronic conditions -or- a minimum of 5 year's experience as a Registered Nurse in an acute care and/or home care setting managing adults.

Preferred:

• Five plus year's 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.