RN Care Manager - Transition of Care Evergreen Health values collaborative, down‑to‑earth individuals and encourages self‑expression. Our diverse workforce provides culturally competent care to our community.
The RN Care Manager – Transition of Care implements the patient’s integrated care plan, resolves patient needs and barriers, and facilitates communication among patients, families, caregivers, providers and the health care team. The RN Care Manager performs delegated functions related to disease states and other conditions that are part of the scope of practice for unlicensed staff members. The focus is to offer individualized assistance to patients, families and caregivers to overcome health care system and community barriers and facilitate consistent and timely medical care across the continuum of care.
Essential Functions Develops a plan of care utilizing clinical quality indicators for all patients on case load, including but not limited to patients with diabetes, hypertension, Coumadin management, complex and comorbidity, etc.
Provides case management, care coordination and patient education to ensure continuous and comprehensive care for patients on case load.
Regularly evaluates plans of care with patients, providers and care team as needed, develops mutually agreed upon goals and provides patient education and behavior change coaching.
Works collaboratively with the health care team including the providers, pharmacists, dieticians, behavioral health specialist, other nursing staff and medical assistants.
Completes transition of care (TOC) follow up from inpatient settings to home and performs follow-up activities with patients as needed after emergency department visits. Includes develops plans of care for hospital transitions to identify factors to decrease the likelihood of readmission.
Completes Annual Wellness Visit (AWV) components in conjunction with PCP.
Ensures case management is implemented and managed to improve continuity and quality of care.
Maintains communication with patients on case load concerning treatment progress and diagnostic reports.
Identifies and coordinates referrals to community resources in regard to patient need.
Completes documentation of all professional activities, contacts and observations promptly and appropriately.
Attends internal and community meetings as assigned and participates in Quality Improvement activities.
Regularly participates in cross‑functional team meetings aimed at improving patient outcomes and in care team huddles to identify priorities, tasks and interventions.
Acts as an advocate for the patient in all activities including nursing assessments, care coordination, care plan development, and communication.
Meets regulatory and agency policy and procedures related to the practice and documentation of case management activities.
Assists with all routine nursing duties as requested or required, including acting as an RN in clinic or through telephone triage.
Thoroughly records information with the EMR to meet clinical and agency requirements.
Actively strives to improve patient service delivery through participation in QI / QA activities. Attends and participates in all in‑services and educational conferences provided by staff and outside vendors.
Qualifications Qualified Candidate will have a current license as a Registered Nurse in New York State, with Bachelors of Science in nursing (BSN) preferred. Possession of Basic Life (BLS) Certification required. At least three (3) years of experience working in a medical office setting, preferably in an HIV / AIDS or other infectious disease practice. Candidate must have familiarity with computers, EMR software (Medent), and MS Office software (Outlook, Word). Candidate must possess a valid NYS driver license and insured, dependable car to use for traveling between office sites. Previous experience providing training is preferred; awareness of and sensitivity to the issues and health disparities faced by underserved populations is essential.
Benefits Multiple comprehensive medical health insurance plans for you to choose from
Dental and Vision coverage at no cost to you
Paid Time Off package that equals 4 weeks of time in your first year
403b with a generous company match
Paid parking or monthly metro pass
Professional development opportunities
Paid lunch breaks