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Population Health Care Manager RN

2 months ago


Hollywood, Florida, United States Community Care Plan Full time
Job Summary

Community Care Plan is seeking a highly skilled Registered Nurse to fill the role of Population Health Care Manager RN - HIV/AIDS. This position will play a critical role in supporting the practitioner-patient relationship through the coordination of care for individuals living with HIV/AIDS.

Key Responsibilities
  • Coordinate and provide expertise to clients living with HIV/AIDS across the continuum of care, promoting compliance with preventative care measures.
  • Develop and implement healthcare interventions to facilitate care at the lowest level possible, focusing on closing immediate goals and empowering clients to self-manage chronic conditions.
  • Work as part of a multi-disciplinary team to identify clients with highest level of morbidity, risk, lack of adherence, barriers to access or retention in care, and implement a plan to address these needs.
  • Conduct or participate in multidisciplinary case staffings and team huddles to review strategies, identify clients or providers with immediate needs, and develop a plan of action to provide quality care.
  • Analyze clinical information to identify clients and determine eligibility and appropriateness for enrollment in the Ryan White Disease Case Management program.
  • Provide outreach to clients identified as having chronic conditions not well managed or with multiple gaps in care and in need of preventive services.
  • Conduct thorough needs assessments, including risk stratification, to determine health, psychological, educational, and social needs, and the level of care requirements.
  • Develop individualized care plans in collaboration with the physician and client, establishing specific, measurable, achievable, realistic, and time-bound goals.
  • Collaborate with the healthcare team to assess progress toward individual health care goals, optimize patient adherence to medical plans of care, and complete electronic referrals, medication refills, and pend to primary care providers as appropriate.
  • Assess barriers when clients have not met treatment goals, are not following treatment plans of care, or have not kept important appointments.
  • Update client care plans as changes in status occur and at least quarterly, communicating with the multidisciplinary team as indicated.
  • Provide client education on disease processes and healthy lifestyle changes, reminders, and/or telephone calls to improve self-management of specific conditions consistent with clinical practice guidelines.
  • Maintain requirements of documentation as reflected in the Ryan White Service Delivery Model to meet compliance with quality standards and acknowledge patient rights on confidentiality issues, maintaining patient confidentiality at all times, and following all HIPAA guidelines and regulations.
Requirements
  • Registered nurse licensure in the State of Florida.
  • Certified case manager or certified diabetes educator preferred.
  • Minimum of five years of clinical experience or two years of case or disease management experience in a Ryan White service provider, health system, health maintenance organization, or disease management organization with experience in HIV/AIDS care.
  • Knowledge of Microsoft Office and internet software.