Clinical Nurse Care Manager

Biltmore Family Medicine, an independent physician practice located in Asheville, North Carolina, is searching for an RN to join their team as a Clinical Nurse Care Manager.

The Clinical Nurse Care Manager provides ongoing care coordination to individuals with both physical and behavioral health conditions. Patients with at least two chronic conditions qualify for more intensive management to ensure understanding of the treatment plan and that their conditions are managed as expected. Additionally, patients who frequent the emergency room and hospital for management of their chronic conditions are a focus for this position and qualify for Chronic Care and Transitional Care Management. This intensive care management includes medication reconciliation, disease management and education and discusses ED / hospitalization encounters with patients to improve outcomes.

JOB DUTIES

• Care Managers work in concert with the Primary Care Provider (PCP) and the community to coordinate a full continuum of health care services considering the patient’s unique social and cultural dynamics
• Assess patients for conditions and concerns that can be addressed through community care management
• Act as a liaison between the PCP, local Health Department (HD), Department of Social Services (DSS), local hospitals, and other community agencies by coordinating health care services in concert with the PCP
• Collaborate with network providers in assuring appropriate client management
• Build and maintain relationships with community service providers through collaboration, networking and educating at community functions
• Assist patients in addressing concerns as needed through referral for assessment, counseling and communication with office providers
• Maintain appropriate client documentation in the EHR
• Develop and implement individualized care management plans for identified clients
• Provide direct follow-up and outreach services via face to face or phone encounter
• Educate clients and families on the importance of medical care management and the proper method to access care within the medical home environment
• Educate recipients about disease states to include medication adherence, prevention and risk factor reduction
• Ensure follow-up with hospital discharge instructions for high risk, high acuity, high cost recipients; ensure continuity of care
• Act as a liaison to providers to ensure the use of Evidence Based Practices
• Assist providers with coordination of services for high risk, high acuity, high cost recipients by implementing Evidence Based Practices
• Advocate for patients to receive services that will improve their health condition
• Assess patients’ plans of care for any duplicate or unnecessary services to control costs to payor
• Audit charts and compile data to support the disease centered initiatives
• Responsible for maintaining patient and family confidentiality in accordance with HIPAA
• Other job duties as required

QUALIFICATIONS

• Degree in Nursing
• Experience in direct patient care / managed care is highly preferred
• Compassionate, caring individual for patient care
• HEDIS Quality Measures experience
• Excellent communication and customer service skills required. Preferred proficiencies in Microsoft Office.
• Ability to work independently, while collaborating with other team members