Registered Nurse Care Manager

Registered Nurse Care Manager

The Registered Nurse Care Manager will focus on improving the health of individuals with chronic conditions and complex medical or psychosocial needs, from providing longitudinal and intensive care management, to addressing transitions of care post-discharge. This person will work collaboratively with an interdisciplinary care team to identify and address gaps in care including planning, implementing, and monitoring individualized interventions to support patients. This includes building supportive, professional, and compassionate relationships with patients, providing appropriate member self-management education on their specific healthcare needs, and developing and managing a patient-centered, comprehensive care plan with the goal of promoting optimal, achievable outcomes for the patient. This person will assist with optimizing patient care across the healthcare continuum and manage the patient closely to help prevent avoidable emergency room visits and hospital admissions. This person will also address patients who have been newly discharged from an inpatient setting, with a focus on avoiding complications and readmissions. This person will work to coordinate and facilitate quality, cost-effective care while minimizing fragmentation of the healthcare delivery system for CKD and ESRD patients. This person will act as a resource for patients and their families, the local care team, and other healthcare professionals.

Essential Functions

• Perform comprehensive clinical assessments on complex patients, develop and maintain a member-centric plan of care, execute appropriate interventions, evaluate outcomes, and adjust plan as needed.
• Advocate for patient, ensuring their optimal well-being and the highest quality of care.
• Provide the patient with the appropriate education, support, and materials to facilitate informed decision making about their healthcare.
• Assess patient conditions in conjunction with the care team, such as the discovery of unreported medical and social conditions, changes at home that may lead to adverse outcomes, or barriers to compliance. Ensure these concerns are referred to the appropriate sources for attention in a timely manner.
• Utilize clinical judgment, independent analysis, critical thinking skills, time management skills and detailed knowledge of case management programs.
• Monitor population health data and identify opportunities to provide targeted patient intervention, including generating and analyzing reports as needed for identifying and managing against trends, anomalies, and areas of concern
• Follow evidence-based medicine and remain current on advances and trends in renal care treatment, guidelines, policies, and procedures.
• Deliver clinical care in a variety of settings including Strive’s dedicated clinic, partner nephrologist offices, patient homes, skilled nursing, assisted living facilities, and via telehealth sessions.
• Perform Transitions of Care Management functions including, but not limited to, identifying and outreaching to newly discharged patients, assessing for and addressing immediate needs and risk for potential complication, comprehensive medication reconciliation, patient education, TCM care planning, coordinating additional care needs, etc.
• Collaborate with all levels of the clinical team to improve processes, communication, and team skills needed to provide the best care to our patients. Act as a resource and provide support to other clinical staff members, leveraging clinical expertise.

Minimum Qualifications

• BSN or MSN degree from accredited school of nursing required
• Current active licensure in any state within the US required
• At least two 2 years complex care management, transitional care management, or equivalent experience in a healthcare environment
• Minimum of 5 years’ experience in clinical nursing required
• Current BLS certification
• Business travel
• Internet Connectivity - Min Speeds: 3.8Mbps/3.0Mbps (up/down): Latency <60 ms

Preferred Qualifications

• Working knowledge of care management and coordination
• Ability to work both independently and collaboratively as a member of a team
• Must be able to independently travel to assigned locations including clinical sites and members’ homes
• Must have valid state driver license, be able to drive a car, meet company driving standards, and comply with company policies.
• Must be able to see patients autonomously.
• Certification by a nationally recognized case/care management organization or agreement to obtain within 6 months of hire.
• Excels at developing strong patient and family relationships that foster engagement and best outcomes.
• 3 years’ experience in renal, ER, ICU, Cardiac, or Ambulatory Complex case management nursing.
• Demonstrated knowledge and understanding of data and managing clinical, financial, and patient satisfaction outcomes.
• Demonstrated experience and effectiveness in a change agent role.
• Complex Case Management experience in a Managed Care environment.
• Previous experience with CKD and ESRD patients. · Working knowledge of CMS STARS and/or NCQA HEDIS.
• Excited to work in a growing environment where you can contribute to building and evolving processes to continuously improve our patients’ experience, outcomes, and clinic efficiency.