Chronic Care Management Registered Nurse
2 weeks ago
The Chronic Care Management Registered Nurse plays a pivotal role in overseeing members with high-risk chronic conditions. This position is under the guidance of the Director of Care Management and focuses on enhancing patient education, supporting self-management, and ensuring timely access to healthcare services to optimize both quality and financial outcomes.
Key Responsibilities:
- Work collaboratively with healthcare providers and practice staff to identify members suitable for care management, adhering to established criteria.
- Conduct comprehensive initial and ongoing assessments for the designated population, addressing both physical and psychosocial aspects.
- Develop and execute a personalized care management strategy that meets the unique needs of each member, involving family where appropriate.
- Establish mutually agreed-upon care objectives with members and their families, focusing on actionable self-management goals.
- Regularly assess the effectiveness of care plans, making necessary adjustments to reflect evolving needs and goals.
- Engage with the healthcare team to modify care plans as required, participating in care conferences to discuss member progress and challenges.
- Identify and leverage community resources to support members and their families, facilitating access as needed.
- Encourage self-management among members, empowering them to achieve optimal wellness and independence.
- Conduct follow-up communications with members recently discharged from acute care, particularly those at high risk for readmission.
- Coordinate with various healthcare providers to ensure seamless transitions of care and optimize clinical outcomes.
- Maintain accurate and timely documentation in compliance with current standards and policies.
- Participate in team meetings and contribute to departmental initiatives, supporting the onboarding of new staff and fostering teamwork.
Qualifications:
- Associate Degree in Nursing required; BSN or advanced degree preferred.
- A minimum of five years of nursing experience, particularly in care management or home care settings.
- Current RN licensure in North Carolina or a Compact state, in good standing.
- Knowledge of care management principles and Medicare benefits is essential.
Skills:
- Strong communication skills, both verbal and written, with the ability to engage effectively with members and healthcare teams.
- Proficient in Microsoft Office and relevant software applications.
- Ability to manage multiple priorities and work independently within the nursing scope of practice.
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