Care Manager RN
2 months ago
We are seeking a skilled Registered Nurse to join our Care Team as a Care Manager RN. As a key member of our integrated Care Team, you will work closely with patients, their medical providers, and other healthcare professionals to develop and implement personalized care plans.
Key Responsibilities- Work closely with patients' medical providers to develop and continually adapt care plans
- Perform in-home care management visits to execute care management plans
- Monitor biometric data and follow approved protocols for any necessary interventions
- Inventory and reconcile medications and coordinate with pharmacists and prescribers
- Perform patient health assessments and surveys as required
- Deliver individual and group education on chronic kidney disease, end-stage renal disease, dialysis, and associated comorbidities
- Encourage medication and treatment adherence through frequent contact with patients
- Engage family and social support groups in the education and care of patients
- Serve as the primary point of contact and be the first call when patients have questions
- Provide education and coaching around medications, medical conditions, diet, exercise, and lifestyle choices
- Facilitate conversations around proactive care decisions, especially relating to advance care plans and end-stage renal disease treatment modalities
- Obtain vital signs when visiting patients and escalate any concerns to the provider
- Initiate patient relationships through enrollment and onboarding processes
- Perform post-op and hospital discharge visits to help patients through vulnerable transitions
- Review and document patient updates and progress in care management platform
- Coordinate with dialysis providers to ensure transitions of care are seamless
- Frequent local travel to perform in-home visits
- Infrequent domestic travel may be required, primarily for training
- Self-starter with the ability to work independently with minimal supervision
- Ability to show empathy and quickly build relationships with patients and physicians
- Graduate of an accredited School of Nursing
- Currently licensed as a Registered Nurse in the State of the posted location
- 2+ years previous experience working in care management and/or with CKD/ESRD patients
- Ability to take call remotely on some nights and weekends
- Excellent verbal communication skills both in person and on the phone
- Familiarity with Microsoft Office and mobile phone and web-based applications
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