Nurse Care Manager

1 month ago


Yuma, United States sunsethealth.com Full time
  • Functions as a liaison for patient/caregiver/family in navigating the continuum of care and serves as a patient advocate in inter-disciplinary meetings.
  • Collaborates with the patient-centered medical home inter-disciplinary team including providers, pharmacists, dentists, behavioral health providers, chronic disease specialists, community health workers, and nurse/nursing support personnel to achieve patient outcomes.
  • Interacts with patients, caregivers, provider teams and the community to achieve continuity of care, coordination of services, timely follow-up, and care planning.
  • Identifies early risk factors, conducts ongoing health assessments, and develops and maintains accurate care records of each referred patient within the electronic health record.
  • Collaborate with health plans, hospitals, and utilize internal reporting capabilities to identify patients who have a recent hospitalization or emergency department visit. Distributes patient follow-up to the Chronic Disease Specialists for outreach and appointment scheduling.
  • Proactively identifies and addresses barriers to care. Maintain a current list of community agencies and resources to provide to patients, caregivers, and provider teams.
  • Provides support services and/or appropriate referrals for patient, caregiver and family as recommended by the inter-disciplinary teams.
  • Assures quality of care by adhering to evidenced-based guidelines; measures health outcomes against patient care goals; makes recommendations to the care team when necessary.
  • Participates in the Quality Program through incident reporting and identifying opportunities for
  • Participate in the Compliance Program through fraud, waste, and abuse prevention, detection, and reporting; and protecting patient confidentiality under HIPAA.
  • Participate in the Infection Control Program through following hand washing and Bloodborne Pathogen safety and exposure protocols.
  • Other duties as

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