The Nurse Care Manager reports to the Director of Clinical Operations and the Administrative Director for Primary Care and Clinical Integration. Under the general supervision of the Practice Physician Medical Director, and departmental policies, the Nurse Care Manager is integrated into the practice-based healthcare team to work in partnership to promote patient-centered care, maintaining frequent contact with the primary care providers and medical home team members.
The Nurse Care Manager will enhance delivery of care and promote care while actively participating in interdisciplinary patient-centered team meetings and huddles/collaborative care rounds. All
performed in this position reflect the age specific needs of the patients. Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another.
Works collaboratively with the care team to identify and case manage patients with a high risk of adverse health outcomes in a primary care setting ensuring open communication patient status with providers and office staff. Sets up and implements primary care medical home model and administers evidence-based healthcare, utilizing innovative thinking and understanding of healthcare delivery system access points and services.
Facilitates communication between members, providers, and stakeholders to coordinate and implement action plans aimed at improving the patients’ total health and attaining desired patient outcomes. Provides comprehensive screenings, assessments, care coordination services, disease education and self-management support with patients who have chronic health conditions, with particular attention to diabetes, depression and coronary artery disease in the office or home setting as needed.
Provides detailed education to patients about their specific chronic illness, including pathology signs and symptoms, complications and medications used in treatment. Conducts and/or reviews medication reconciliation and works with provider/team pharmacist as needed to assist with medication management to support patients to enhance medication adherence. Works one-on-one with patients meeting individual healthcare needs; develops a plan of care, interventions and treatment goals with patients that promote improved health outcomes and quality of life and reviews with provider and clinical team members.
Addresses barriers to optimum patient health; advocate for patients to ensure access and timely service delivery across the continuum of care. Ensures safe, effective and efficient care for all patients transferring to home from the Emergency Department; responsible for timely telephonic follow up of complex patients who present to the ED. Utilizes behavior techniques, such as motivational interviewing, to assist patients with establishing self-management goals and action plans with timeframes.
Acting as a liaison, coordinates care and performs outreach identifying and utilizing cultural and community resources; providing access to culturally and linguistically appropriate services as needed. Utilizes an interdisciplinary team approach to address opportunities to plan and coordinate care; acts in a supportive capacity to other team members (medical assistants, patient service representatives, practice managers, providers, etc.) in supporting patients and their treatment plan.
Utilizes the Electronic Medical Record (EMR), chronic disease registry, and Current Care reporting to prioritize patient follow-up. Generates quarterly reports on service volume, distribution of patients by plan, and types of services provided; analyzes data and develops and implements performance improvement strategies to meet and exceed quality of care expectations. Maintains knowledge of contemporary, professional nursing practice within the legal framework of Rhode Island Nurse Practice Act.
Attends training and retraining as needed, to maintain current knowledge of patient’s care practices and procedures. Shares best practices among all teams, services as a medical home advocate and advisor, leads by example to support a positive work environment and encourages all staff to do the same. Participates in establishing protocols, risk management activities, practice performance improvement initiatives and quality measures with interdisciplinary team.
Maintains a safety, environmental and infection control in accordance with Brown University Health policies, procedures and objectives. Maintains a safe environment for patients, visitors and staff. Performs other related duties as assigned.
Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing. BASIC KNOWLEDGE: Graduate of a school of nursing, Baccalaureate in Nursing preferred (BSN), with current license to practice as a Registered Nurse in the State of Rhode Island. Conformity to the Code of Professional Nurses.
Understanding of the provisions of the Nurse Practice Act of the state of Rhode Island. Demonstrates knowledge and skills necessary to provide care to patients with consideration of aging processes, human development stages and cultural patterns in each step of the care process. Current BLS required.
American Academy of Managed Care Nursing (CMCN) certification, certification as a Diabetes Outpatient Educator (CDOE) or other chronic care area preferred. Excellent organizational skills, presentation skills, decision-making skills and ability to successfully prioritize multiple tasks.
Three to five years’ experience in either a community health setting, primary care practice setting coordinating patient care/disease management, public health, chronic disease management, community nursing or case management preferred.
- $74,256.00
- $148,512.00 EEO Statement: Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment. Location: Warwick
- 43 Jefferson Blvd. - 43 Jefferson Blvd. Warwick, Rhode Island 02888 Work Type: M-F 8:00
- 5:00PM Work
Day Daily Hours: 8 hours Driving Required: No