Main Function: A Registered Nurse working in conjunction with a care team to identify and proactively manage the care needs of high risk patients within the primary care practice setting. The Care Manager provides assessment, care coordination, advocacy and coaching for identified patients that are at risk for hospital admissions or emergency room visits. The Care Manager uses established Finger Lakes Health System Agency (FLHSA) CMMI grant criteria to identify at-risk patients, and determines the drivers of risk in conjunction with the patient, family, physician and ancillary health care providers. An integral, professional member of the practice's care team, the Care Manager measures the impact of care coordination interventions, and regularly re-assesses the patient's risk for incurring adverse health outcomes.
Required Job Specific Competencies:
• Ability to develop and support a practice based care management model by providing on-site and telephonic services i.e. wellness, health coaching, self-management techniques, disease management and case management including coordination with community services per FLHSA standards.
• Identifies per FLHSA specifications and practice providers, high risk patients needing care management services. Provides education, support and outreach to patients over the phone and in person ensuring all aspects of FLHSA programs are met for family practices. Prompts patients to complete outstanding tests.
• Interacts closely with clinical teams to identify care gaps and improve clinical outcomes for patients with chronic conditions such as diabetes.
• Active support for Thompson Practices quality programs, including PCMH and Diabetes Recognition Program.
• Functions independently and is able to utilize sound judgment and critical thinking skills when interacting with physicians, members and practice staff.
• Scans the medical literature routinely for updates on clinical practice guidelines, new developments in the management of chronic diseases and communicates and disseminates information to staff.
• Ensures a high level of patient satisfaction.
• Actively guards the confidentiality of sensitive information including but not limited to the patients, staff and the health system. • Complies with all required Joint Commission, state and federal regulations.
Qualifications: (Licenses, Certifications)
• Current New York State Registered Nurse license required
• CPR certification
• Excellent communication skills and ability to form collaborative partnerships across all service settings.
• Working knowledge of the provision of health care in a variety of settings.
• Knowledge of community resources required.
• Proficient in the use of Electronic Medical Records (EMR); ability to create reports on own and interface with EMR vendor to develop reports where none currently exist.
• Competent in Microsoft Office products (Word, Excel, Outlook, PowerPoint).
• Effective oral and written communication skills, communicates information correctly.
• Self-directed, self-starter and able to implement new programs and encourage participation by patients and staff.
• Accepts responsibility and follows through on projects and activities.
• Patient Centered Medical Home and Diabetes Recognition Program knowledge and experience a plus.
• Ability to assimilate new information and technologies into daily work.
• A graduate of an approved school of nursing or having met requirements of the New York State education department is eligible for licensure, and currently holds a NYS license.
• Complies with annual Joint Commission and organizational competencies.
•3- 5 years of clinical nursing or social work experience preferred, preferably with 3-5 years of community health experience, with the adult population.
• Electronic Medical Record experience required
• Database entry and reporting preferred
• Care Management experience preferred
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