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Patient-Centered Healthcare Home Nurse Care Manager RN
2 months ago
We are seeking a skilled Nurse Care Manager to join our team at Compass Health Network. As a key member of our person-centered integrated care team, you will provide direct clinical and medical services to individuals enrolled in our Health Care Home program.
Responsibilities- Manage a caseload of up to 250 Healthcare Home patients, providing personalized care and support.
- Develop and implement yearly care plans in collaboration with patients and their families.
- Assist in creating treatment plans that address co-occurring chronic diseases, ensuring comprehensive care.
- Provide education and consultation to community and office-based staff on identifiable health conditions.
- Collaborate with medical providers to ensure seamless care coordination.
- Offer education and support to patients on medical diseases, treatment, and medication management.
- Monitor and analyze HIT tools and reports to identify treatment and medication alerts, hospital admissions, and discharges.
- Review monthly DRVS reports, focusing on targeted population indicators, and communicate findings with providers, clinicians, and patients.
- Perform medication reconciliations for HCH enrollees who have been discharged from the hospital.
- Aid in UDS measure documentation, tracking, and reporting.
- Function as part of a multi-disciplinary team, working collaboratively to achieve patient-centered care.
- Seek culturally competent services and providers to meet the unique needs of each agency consumer and family member.
- Report to the Regional Primary Care Nursing Director for guidance and questions regarding clinical supervision.
- High School diploma or equivalent required; Associate or Bachelor's degree in nursing preferred.
- Proficiency in Microsoft Office Suite and Electronic Medical Records preferred.
- Registered Nurse (RN) licensure in MO required.
Compass Health Network is a nonprofit healthcare organization dedicated to providing accessible, comprehensive, and compassionate care to our communities. We are a Federally Qualified Health Center (FQHC) and a Community Mental Health Center (CMHC), committed to operating with the highest ethical and professional standards.
