Care Manager Nurse (RN) - Population Health - Day

Full time (80 hours biweekly)

Day shift

This position is remote (work from home)

Required to meet with patients in a practice, patient home or in the community

Position concentrated in and around Ephrata area (Lancaster county)

Job Description:

Under general supervision, the Population Health Care Manager Nurse coordinates and monitors the health needs of patients, such as pain, symptom management, behavioral health, DME’s, home health, assistance with daily living, and/or community resources. The Care Manager works closely with patients, caregivers, family members, physicians, hospital care managers, and ancillary service providers to achieve the patient’s maximum functional potential. This position provides on-going support through comprehensive assessment and care planning. The care manager ensures patient’s cases are in compliance with regulatory guidelines.

Duties and Responsibilities

1. Utilize Motivational Interviewing techniques as a patient-centered approach to activate patients in self-management of their chronic conditions with the goal of improved symptom management and interruption of a negative disease trajectory
2. Maintain a caseload of patients according to department policies.
3. Meet patients in their home, primary care office, and other locations as identified.
4. Identify, enroll and manage patients in program for Complex Case Management/Chronic Disease Management
5. Develop and implement care plans to maximize healthcare outcomes and facilitate wellness with periodic review and update according to department protocols.
6. Perform medication review and teach-back to ensure patient understanding and ability to adhere to medical regimen.
7. Collaborate with PCPs, Specialists, and Hospitalists to effectively implement a patient-centered care plan.
8. Perform patient outreach according to established protocols and document in electronic medical record.
9. Identify, execute, and track needed referrals to care and community resources
10. Provide resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, right time.
11. Assist patient in advanced care planning to complete Advanced Directives.
12. Documents member’s assessments, care plans, goals and interventions in electronic medical management system according to NCQA standards.

Qualifications

• Minimum Experience:
  • 3-5 years
• Minimum Education:
  • Bachelor's Degree
• Preferred Field Of Expertise:
  • Utilization management, case management, or clinical nursing specialty
• Required Certification:
  • Registration and current RN license in PA
• Physical Demands:
  • Mostly sedentary work
  • Occasional prolonged standing/walking

#remote