RN Care Manager

6 days ago

Nashville, Tennessee, United States Wellvana Integration Partners, LLC Full time

About the Role:

We are seeking a highly skilled Registered Nurse (RN) to join our team as a Care Manager - Patient Advocate. In this role, you will be responsible for managing the care of rising risk and high-risk patients, promoting effective education, self-management support, and timely healthcare delivery to achieve optimal quality and financial outcomes.

Key Responsibilities:

  • Telephonically engage assigned patients to specified cadence and frequency based on healthcare status and need, building relationships and trust to support the patient and assist them as they navigate the healthcare ecosystem.
  • Enroll patients in designated programs based on chronic conditions or recent events, such as discharges from Emergency Department or Inpatient facilities.
  • Ensure patient adherence to assigned care plans and prescribed medications.
  • Coordinate with aligned practices to ensure timely visits and follow-ups based on protocols for chronic condition and discharge management, close care gaps, and monitor timely refills to medications.
  • Perform whole-person assessments for identified individuals, including physical, social determinants of health, and psychological barriers and concerns for members as appropriate, leveraging multi-disciplinary team members to address and resolve issues.
  • Identify problems or gaps in care and offer opportunities for intervention.
  • Collaborate as needed with providers and other healthcare team members, including inpatient case management staff and outpatient providers, to transition and facilitate care across the healthcare continuum to optimize clinical and financial outcomes.
  • Cooperate with appropriate healthcare team members to perform root cause analysis on readmissions.
  • Provide insights and recommendations for hospice and palliative eligible patients.
  • Implement a member-centric care management plan, utilizing SMART goals, that address practitioner care goals, member/family concerns, and available resources.
  • Provide ongoing evaluation of the effectiveness of the plan of care in meeting established care goals through collaboration with the affiliated practice, patient, and/or family-caregivers.
  • Revises the plan of care as needed to reflect changing needs, issues, and goals and monitors and evaluates the progress of the member at prescribed minimal intervals.
  • Maintain accurate and timely documentation, ensuring documentation meets current standards and policies.
  • Meet established goals for productivity, including panel size, enrollment, retention, quality, and standard call center metrics.
  • Maintain a working knowledge of, and adhere to, applicable federal and state regulations, including laws related to patient confidentiality, the release of information, and HIPAA.
  • Abide by the organization's compliance program and requirements.
  • Maintain appropriate clinical licensure in good standing.
  • Participate in regular team meetings and peer review activities. Participate in departmental and organizational committees, as applicable. Assist/support in the orientation of new personnel. Promote collaborative teamwork.
  • Meet with care management leadership team and the care management/clinical coordination team on a regular basis to provide member updates, identify issues, and develop strategies for resolution.
  • Maintain appropriate professional boundaries.
  • Interact respectfully and effectively with others, focusing on the achievement of organizational goals and objectives through a commitment to teamwork.
  • Appropriately update departmental leadership with necessary information.
  • Utilize teach-back methods with patient/caregiver.
  • Support training of new telephonic staff members.
  • Perform other duties as needed.

Requirements:

  • Associates degree in nursing required.
  • BSN preferred.
  • Must hold a current/active TN compact RN license.
  • Minimum two years of nursing-related care experience, preferably in a primary care office or call center setting.
  • Case Management, Care Management, Care Coordination, telephone nursing management, and/or Disease Management experience.

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