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Care Manager, RN
Saint Francis Health System. Provide patient-centered medical home and care coordination across the health care continuum .
About the role
Key responsibilities & impact- Provide patient-centered medical home and care coordination across the health care continuum
- Collaborate with physicians, staff and other healthcare professionals to maintain safety, best practices and high-quality care
- Coordinate self-management support and disease registry activities
- Oversee and maintain the disease registry database
- Identify patients overdue for visits, labs or referrals and arrange follow-up services
- Identify patients not meeting clinical goals and arrange appropriate follow-up
- Create patient-, physician- and office-level quality performance reports
- Conduct or facilitate pre-visit chart reviews, preventive care reviews, immunization reviews and chronic disease interventions
- Complete pre-visit or office visit forms and communicate reviews to providers
- Identify specific diagnosis codes to support optimal HCC outcomes
- Support patients and families with chronic disease self-management, medication adherence and health behavior change using the 5A's approach
- Provide or arrange patient education and assist with shared medical appointments
- Assess patient understanding of disease processes, treatment plans and lifestyle changes
- Coordinate care across the continuum and act as a liaison among patients, families, physicians, clinical staff, departments, hospitals and specialty providers
- Follow up with patients after hospital discharge and at clinically appropriate intervals
- Advocate for patients, address concerns and connect patients with community resources
- Participate in quality improvement activities and collaborate with clinic management on office goals
- Participate in or coordinate quality improvement committees and develop tools for optimal patient outcomes
- Meet with other medical home care guidance nurses for information sharing and continuing education
- Prepare data and electronic correspondence
- Maintain confidential patient health records
- Lead others performing the same work without supervising them
Requirements
What you’ll need- Completion of the basic professional curricula of a school of nursing approved and verified by a state board of nursing, with a diploma or degree
- Valid multi-state or State of Oklahoma Registered Nurse License
- Basic Life Support (BLS) certification
- 3–4 years of related experience
- Understanding of systems and processes in outpatient medical group practices
- Effective teaching techniques applying adult learning principles
- Ability to coordinate appropriate educational materials for patients and support systems
- Professional, appropriate, effective and tactful written, verbal and nonverbal communication
- Ability to maintain complete patient confidentiality
- Knowledge of various payor regulations
- Safety-sensitive position subject to OMMA-related marijuana testing and employment policies
Benefits
Comp & perks- Full-time schedule
- Days schedule