Login

RN Care Manager - Premier Physicians Centers Inc

Location: Westlake, OH

Job Type: full-time

Company: Aledade

Category: Non-Provider

Job Description Apply Now

• Makes transition calls to discharged patients within the designated time frames and  documents and tracks findings. 
• Initiates or accepts referrals from staff for patient needs assessment, determines  eligibility for resource assistance, and makes resource referrals.  
• Provides follow up with individual patients, their families, and referral resources to  ensure contact has occurred and patient needs have been met within limits.  Establishes/maintains positive, ongoing working relationships with other community  agencies, physician offices.  
• Utilizes effective interviewing techniques with strong limit setting abilities.  
• Works closely with physicians, nurses and other medical staff to communicate a  patient’s needs and concerns.  
• Contacts patients for transition of care or follow up care, assesses their needs, identifies  gaps in care, implements care plans if needed, notifies physician of findings.  
• Positive, flexible, and solution-focused attitude.  
• Assesses for potential barriers and provides resources or referrals as needed.  
• Reviews hospital discharge information, assesses patient understanding, and provides  education as needed. Follows up with patients to assure their needs are still being met  after discharge.  
• Provides referrals, education to patients upon their transition and in an outpatient  setting. 
• Identifies patients that may need care management services.  
• Maintains consumer confidentiality according to HIPAA privacy rule.  
• Provides leadership for new or less experienced team members by training, developing,  coaching, mentoring and being a positive role model.  
• Uses clinical judgment, critical thinking and problem-solving techniques when assessing  patients in order to promote optimum patient outcomes and decrease potentially  preventable ED visits or hospital admissions/readmissions. 
• Provides current and appropriate general health and wellness education throughout  interaction with patients as well as teaches self-management skills.  
• Uses oral and written communication to convey pertinent information to members of  the health care team in a timely manner.  
• Effectively communicates with the disabled and elderly populations and general public  by phone.  
• Communicates in a collaborative, effective manner with others and maintains good  working relationships.  
• Provides ongoing care management for a diverse population of persons with chronic  illnesses or disabilities of all types.  
• Evaluates and develops care plans for care managed patients based on patient needs;  collaborates with team as needed.  
• Identifies and documents psychosocial needs; sends community referrals as needed and  monitors for responses. 
• Identifies gaps or barriers in self-management and provides education to assist as  needed.  
• Works with patients to close gaps in care; addresses barriers that may impact gap  closure 
• Coordinates patient services as needed. 
• Educates patients on disease processes, health maintenance, medication management  and self-management skills. 
• Encourages patients to make healthy lifestyle changes. 
• Utilizes a positive proactive approach to function as a health advocate to engage  patients. 
• Interacts with the care team on challenging cases.  
• Separates personal from professional interactions with patients and maintains  professional/ethical boundaries.  
• Follows “best practice”, policies, and procedures.  
• Participates in continuous quality improvement to enhance care transition and care  management of patients.  
• Maintains required documentation for all care transition and care management  activities. 
• Works with leadership to continuously evaluate processes, identify problems, and  propose/develop process improvement strategies.  
• Participates in regularly scheduled team and inter-organizational meetings.  
• Remains organized, prioritizes and communicates effectively to patients, families,  clinicians, and team members.  
• Assesses the healthcare, educational, and psychosocial needs of the patient/family.  
• Provides self-management support and empowers the patient to achieve optimal health  and independence.  
• Assists as needed to ensure smooth transitions with new employees as well as  successful functioning of the department. 

• Active, clear, unrestricted Ohio RN license  
• Minimum level of education desired for candidates in this position is an Associate  degree or an equivalent combination of education and experience may be considered.
• At least two years of experience working with individuals with physical disabilities in a  home health care, medical, or behavioral health environment is required.  
• Ability to work independently under general instructions, self-directed and motivated.
• Excellent verbal and written interviewing and assessment skills.  
• Knowledge of major chronic disabling illnesses for persons of all ages, disease processes,  and normal aging.  
• Ability to comprehend written material related to essential job functions.  Demonstrates the ability to handle stressful situations appropriately. Demonstrates the ability to work as part of a team.  
• Serves as a resource to other team members.  
• Experience with Microsoft Office, proficient typing skills with the ability to navigate a  Windows environment.  
• Sensitivity and experience in working with different cultures.  
• Demonstrates excellent written, verbal, telephonic, interpersonal and listening  communications skills; positive relationship building.  
• Demonstrates the ability to function effectively in a fluid, dynamic, and rapidly changing  environment.  
• Ability to analyze, evaluate, and implement a reasonable course of action based on  available information.  
• Demonstrates patient focused interpersonal skills to interact in an effective manner  with practitioners, the interdisciplinary health care team, community agencies, patients,  and families with diverse opinions, values, religious and cultural ideals.  
• Strong organizational skills and multitasking abilities.  
• A personal vehicle, valid State of Ohio motor vehicle operator’s license and conformity  with insurance coverage limits are required. 

Apply Now