RN Care Manager managing high risk and chronic illness at NorthLakes Community Clinic. Focused on integrated, quality care and patient engagement within the clinic setting.
Responsibilities
Manage high risk and chronic illness to promote whole-person, integrated, quality care
Conduct in-office patient visits as outlined in care plan
Create and promote engagement with a care plan, developed with the patient, primary care provider and/or specialty care provider and family/caregiver(s)
Support the delivery of integrated, whole-person care in family medicine, recovery and psychiatric care
Engage patients in self-management and shared decision-making
Increase utilization of preventative care services
Promote timely access to appropriate care to reduce emergency room utilization and hospital readmissions
Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals
Work with internal providers on coordinating schedules, getting a client in to other service lines as needed
Facilitate patient access to appropriate medical and specialty providers
Assist with the identification of “high-risk” patients with a chronic illness and coordinate care
Assess for social drivers of health and work with Community Health Workers on integrated Care Management
Attend all Care Management training courses/webinars and meetings
Participate in quality improvement efforts by utilizing dashboards, tracking tools and providing quality reporting data monthly
Follow protocols, clinical policy and procedure in collaboration with the Primary Care Provider/Specialty Care provider
Perform in-clinic triage and medication refills
Conduct nursing assessments according to assessment tools to determine services and service level of care needed
Under provider direction perform and/or assist in inductions utilizing COWS, administer patient injections and provide education on naloxone
Provide education about Neonatal Abstinence syndrome, support systems, and concerns
Monitor medication adherence and check PDMP
Requirements
Associates Degree in Nursing
RN with two+ years related experience and/or training
Electronic Health Records, preferably Epic
Benefits
Medical and dental insurance
Employer paid group term life and disability
Employer contribution toward Health Savings Account
Flexible Spending Accounts
Paid Time Off (PTO), Paid Holidays and Paid Leave Bank
403(b) with a 4% employer match
Various voluntary benefits: Vision Insurance, Supplemental Life, AD&D and Disability, Tuition reimbursement, Health and Wellness reimbursement program, Employee Assistance Program, and other specialized behavioral health services and resources for employees and family members
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