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Patient Centered Healthcare Home Nurse Care Manager RN

1 month ago

Union, United States Compass Health Network Full time

Due to rapid expansion in all of our clinics, we are offering up to $4,000 sign on bonus*. We are eager to be able to continue to serve clients in our service areas and need you to make this happen

The Nurse Care Manager is part of the person-centered integrated care team and provides direct clinical and medical services to persons enrolled in the Health Care Home through a “whole person” approach.

The candidate will be required to travel between Union and High Ridge locations. This is a full-time, benefit eligible position. The schedule is Monday - Friday.

Responsibilities Include: 

• Responsible for case load of up to 250 Healthcare Home patients
• Meet with assigned clients to yearly care plans.
• Assist in developing treatment plan healthcare goals for individuals with co-occurring chronic disease
• Meet with assigned clients prior to monitor/educate on client’s medical needs as needed
• Provide consultation and education for community and office-based staff about identifiable health conditions
• Assist in contacting/collaborating with medical providers regarding significant health information
• Provide education to clients on medical diseases, treatment, and medication
• Monitor HIT tools and reports for treatment and medication alerts and hospital admissions/discharges
• Review monthly DRVS reports, focusing on targeted population/indicators. The NCM will analyze the information and communicate/collaborate with providers, clinicians and patients
• Perform Medication Reconciliations for HCH enrollees who have been discharged from the hospital
• Aid in UDS measure documentation/tracking/reporting
• Function as part of a multi-disciplinary team
• Will seek culturally competent services and service providers to meet the unique cultural needs of each agency consumer and family member
• Report to Regional Primary Care Nursing Director for guidance and questions regarding clinical supervision issues (PC only)
• Other duties as assigned