Nurse Care Manager 2

1 week ago


Philadelphia, Pennsylvania, United States HealthEcareers - Client Full time
Nurse Care Manager 2 Job Description

Job Summary:

The Registered Nurse (RN) Care Manager provides a holistic, trauma-informed, and patient-centered approach in caring for patients seen through HealthEcareers - Client's Healthcare Services. Key roles include:

  • Serving as a vital member of the healthcare team and contributing to its success.
  • Collaborating with patients, healthcare stakeholders, and primary care providers to provide coordinated intake assessments, goal setting, and plans of care.
  • Assessing, triaging, and responding to patients' acute, chronic, and preventive health and wellness needs.
  • Providing mentorship and guidance to new nurse care managers.

Care Management Responsibilities:

  • Coordinating with primary care providers, behavioral health providers, and other healthcare professionals to implement individual care plans, especially follow-up plans from emergency room or hospital discharges.
  • Information-sharing, goal setting with the patient, pre-visit planning, and after-visit follow-up, exploring gaps in care and working to eliminate them.
  • Educating patients and/or support systems in areas such as harm reduction and/or recovery from substance dependence, disease-specific management, medication management, healthier lifestyle choices, stress reduction, chronic disease management, and pharmacological agents.
  • Facilitating individual or group sessions that provide education to staff and patients on health-related topics and activities that enhance recovery and self-care management.
  • Coordinating care with a focus on critical care transition points (e.g., from hospital/ED to home, from street to housing, from specialist to primary care, from primary care to hospice).
  • Participating in regular interagency, interdisciplinary care meetings for case review and discussion of evidence-based chronic disease management and integrated care best practices.
  • Conducting occasional mobile health visits with patients whose mental/physical/emotional conditions may prevent them from accessing care in a formal clinic setting.

Direct Clinical Care Responsibilities:

  • Demonstrating clinical excellence, flexibility, patience, critical thinking/decision-making, and ability to teach and collaborate with providers and patients.
  • Performing clinical assessments and procedures using universal precautions, aseptic technique as required, and in accordance with proper OSHA standards.
  • Duties include, but are not limited to:
    • Vital signs, including ability to interpret pulse oximetry
    • Performing AIMS assessments
    • Medication injections & immunizations
    • Venipuncture
    • First aid
    • Providing staff training and education to ensure proficiency with medication monitoring, as well as other topics critical to management of the target population.
    • Wound care
    • Facilitating vision screenings and assisting patients with obtaining corrective eyewear.
    • Exploring options for other on-site healthcare services, including podiatry and vaccinations, in collaboration with the Philadelphia Department of Health.
    • Utilizing a harm reduction model and person-centered care delivery.
    • Counseling patients and assessing readiness to change regarding recovery, healthcare, and lifestyle choices.
    • Assessing and managing patients' needs related to acute and/or chronic health conditions.
    • Facilitating scheduling of appointments & procedures, such as colonoscopies, biopsies, radiology studies, chemotherapy, lab testing, medical/dental/psychiatric evaluations, and other health-related activities.
    • Obtaining prior authorization for medications, procedures, or other services as needed.
    • Providing guidance to case management staff regarding symptom assessment of residents with acute and chronic health conditions.
    • Assessing the need for durable medical equipment and collaborating with PCP, medical home, insurer, pharmacy, and/or medical supply company to obtain necessary items.
    • Collaborating with Program Manager and other key stakeholders to identify areas for improvement.
    • Participating in HealthEcareers - Client/Healthcare Services Quality Improvement initiatives.
    • Attending all mandatory HealthEcareers - Client/Healthcare Services mandatory trainings and/or trainings recommended by Direct Supervisor(s).
    • Maintaining nursing licensure and CPR certification.
    • Providing mentorship for HealthEcareers - Client/Healthcare Services nurse care managers who are new to the role.
    • Assisting in running HealthEcareers - Client/Healthcare Services COVID vaccination clinics.

Documentation Responsibilities:

  • Inputting all required care management data into the Electronic Health Record (EHR).
  • Per HIPAA regulations, obtaining all necessary signed written authorizations from residents to coordinate and share information with other healthcare providers, including HealthEcareers - Client/Healthcare Services, and Residential case managers.
  • Ensuring that participants sign an annual Privacy Notice.
  • Maintaining own training, certification, and continuing education activity log for reference at mid-year and annual performance reviews.

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