TCHP Care Manager-RN - CBO Care Management - Full Time - Days
Join to apply for the TCHP Care Manager-RN - CBO Care Management - Full Time - Days role at The Christ Hospital Health Network.
The primary duties of this position involve facilitation of continuity of care across the healthcare continuum. This role acts as a navigator and advocate for better health outcomes for patients served by the primary care physician. The Care Manager is responsible for managing high risk patients with multiple comorbidities or at high risk for hospital admission or readmission. This includes developing and monitoring health promotion, disease management, care coordination and utilization management. The Care Manager will develop care plans in conjunction with the care team to implement interventions that assist moving the patient toward optimal health. The Care Manager will facilitate care transitions after a hospital admission to ensure the patient has a seamless experience and well coordinated care.
Responsibilities
Identify targeted patient populations that would benefit from care management.
Pre-visit planning workflow to ensure care completion prior to visit whenever possible.
Use efficient, accurate point of care reminders for evidence‑based care.
Coordinate patient care services for selected patients across the continuum of care through collaboration with the patient and family and health care providers to achieve optimal patient outcomes.
Communicate with patients after hospitalizations to schedule appointments, assist with medication education, review after‑visit summaries and provide a point of contact.
Collaborate with the Care Team and follow up appropriately to ensure smooth transition of care for patients treated in a facility (inpatient or emergency department), by specialty physicians, or by another health care provider.
Involve patients in activities to improve their health (patient engagement).
Educate patients about self‑management tasks they can undertake to gain greater control of their health status.
Conduct health teaching and health counseling to patients and/or their families.
Identify barriers preventing patients from achieving optimal health, problem‑solve and plan with the Care Team and outside resources to overcome them.
Work closely with providers and clinical staff to assure clinical quality is an ongoing priority in all phases of patient care.
Participate in clinical quality activities and facilitate the implementation of clinical best practices.
Network and collaborate with professional colleagues and outside community agencies to develop best practices.
Coordinate with physician leadership to develop strategies for the high‑risk patient population and coordinate care from office to hospital to home.
Monitor utilization of resources and collaborate with the patient and care team to promote efficient and appropriate use.
Provide leadership in the development of office workflows, collaborating with physicians on the development of care standards with preventive services and chronic disease management.
Lead the health care team by influence and role modeling integrated effective nursing practices, excellent customer service, innovation and providing outstanding support for the physician practice.
Ensure safe practices and report any concerns.
Promote excellence in healthcare delivery to the patient and/or patient family. Identify and facilitate implementation of clinical best practices.
Engage co‑workers and patients in a positive, respectful manner.
Show respect and sensitivity for differences among co‑workers and patients.
Facilitate seamless patient experience by coordinating care with the care team, patient and family.
Ensure complete and accurate documentation in the medical record.
Effectively use all electronic tools to deliver evidence‑based care.
Design effective workflows using population management software, the electronic medical record and registries.
Collect and monitor data related to outcomes.
Participate in performance improvement projects to leverage the electronic medical record.
All other duties as assigned.
Qualifications
Registered Nurse.
Minimum of 3 years of experience.
Autonomous.
Excellent problem solving and critical thinking skills.
Ability to prioritize work and manage multiple demands.
Knowledge of basic computer functions.
Effective communication skills, both written and verbal.
Ability to work both with and for the team.
Ability to show respect and sensitivity to cultural differences in both employees and patients.
Knowledge and support of organization’s goals and values.
Must be current Registered Nurse licensed in the state of Ohio.