RN Care Manager

Title: RN Care Manager

Reports To: Senior Director of Community Care Management

Department: Nurse Care Management

Job Grade: 10C

Employment Status: Exempt

Date: 7/2024

General Responsibilities:

Provide comprehensive screening, assessment, care coordination services, disease education and self-management support to a caseload of moderate to high risk adults with complex chronic health conditions. Coordinate sick visits or additional services as needed. 

Qualifications:

Required Qualifications:

• Current State of Rhode Island RN license, BSN; graduate education preferred
• Certification in Certified Diabetes Outreach Educator (CDOE) within one year of hire
• Experience in community health setting, public health, chronic disease management, community nursing, case management preferred
• Experience working with primary care providers in practice setting to coordinate care and disease management.
• Knowledge of disease management, case management, and chronic care principles
• CPR/BLS certification

Preferred Qualifications:

•          Certification in one or more of the following: Case Management, Diabetes Education, asthma/COPD,   Cardiovascular
•          Candidates who do not meet all the preferred qualifications are encouraged to apply.

Significant Job Functions:

·            Manage a caseload of moderate to high-risk adults with complex chronic health conditions in a community primary care setting.

·            Establish Care Plan, goals, interventions, and contact schedule based on risk category and patient’s identified medical and social needs

·            Promote compliance with disease specific clinical outcomes by providing each individual with self-management supports including:

1.                Disease specific educational materials
2.                Medication review and side effects
3.                Signs and symptoms to watch for and report to provider
4.                Nutritional recommendations
5.                Exercise and activity
6.   Community supports, services and resources including current provider information such as  Pharmacy,    DME, and Home Care providers

·            Care plan and treatment goals including self-management goals

·            Maintain standard precautions at all times

·            Maintain OSHA and HIPAA guidelines

·            Adhere to organizational policies and procedures

·            Maintain and sustain line of communication with supervisor, providers and other staff members

·            Actively participate in performance improvement activities to improve quality of care and safety to assure that the health care team meets and exceeds the established standards of practice and benchmarks

Physical Effort/ Environment:

•             This is a hybrid role. Work may be completed onsite or remotely. Diabetic case management and education appointments are office based. 
•             Moderate physical activity, walking, standing, stooping, and occasional lifting. 
•             Potential exposure to blood-borne pathogens, infectious diseases i.e. respiratory (Tuberculosis), and bio-  hazardous materials. 
•            Manual dexterity for computer use. 
•         Organization skills, neatness; knowledge of safety and infection control standards of practice.

Work Schedule Demands:

·         Full-time position with a base of 40 hours per week.

Communication Skills:

•          Interpret technical medical terminology daily.  Use all available methods of communication with patients, such as            with interpreting, counseling, group discussion, written materials and visual aids.
•          Communicate and identify cultural, social and economical characteristics of the patient population served.
•          Document clearly and concisely in the medical record.
•          Assist with clinical audits; databases as assigned.
•          Communicate in a professional manner with patients, families other staff and outside contacts
•          Communicate effectively and work collaboratively with patients, providers, other members of the health care team,          other disciplines and community agencies.
•          Demonstrate professionalism, leadership skills, triage skills, documentation skills, and teaching skills

Competencies/Additional Skills:

• Strong patient service skills
• Strong problem-solving skills
• Teaching skills
• Triage skills
• Job knowledge- broad knowledge base of relevant professional, technical and clinical information in assigned department.
• Strong Leadership skills
• Documentation Skills
• Ability to communicate effectively and work collaboratively with patients, providers, other members of the work team for performance improvement initiative