Accountable Care Manager

NYC Health Hospitals Woodhull , IL 61490

Posted 2 months ago

Marketing Statement

Woodhull Medical and Mental Health Center is attuned to the healthcare issues that matter to the people of North Brooklyn. Woodhull focuses on preventing disease and promoting healthy lifestyles by reaching out to the community at 15 convenient locations. Woodhull Medical and Mental Health Center is a non-smoking facility.

Job Description

SUMMARY OF DUTIES AND RESPONSIBILITIES:

  • Work at one of our Adult Primary Care clinics to improve the quality of chronic disease care.

  • Focus 50% on direct patient care and 50% on performance improvement responsibilities.

  • Provide direct clinical care, for patients with uncontrolled chronic conditions e.g.: hypertension or diabetes. This can include

  • Educate patients about diagnosis, treatment, medications, and follow-up.

  • Conduct nurse follow-up visits for HTN management, insulin teaching and/or titration.

  • Identify underlying challenges such as socioeconomic, cultural, physical and language barriers.

  • Collaborate with patients, families and care team to address barriers, using strategies such as motivational interviewing and brief action planning.

  • Liaise with social work department to develop strategies to address social determinants (e.g.: homelessness or food insecurity)

  • Organize group medical visits and moderate discussion to optimize peer to peer support.

  • Collaborate with central office staff in the Office of Population Health to implement chronic disease performance improvement initiatives.

  • Report progress bi-weekly on facility chronic disease initiatives.

  • Coordinate and collaborate with facility clinical, nursing and administrative leadership to drive continuous performance improvement for chronic disease management.

  • Educate ambulatory nursing staff on chronic disease initiatives.

  • Monitor adherence of ambulatory nursing staff to performance improvement plans.

  • Track and share quality metrics with stakeholders across the facility.

  • Implement OPH disease management toolkits to drive facility change.

  • Coordinate with OPH and facility leadership to address barriers in achieving improvement goals.

  • Other duties assigned.

Minimum Qualifications

  • Valid New York State license and current registration to practice as a Registered Professional Nurse issued by the New York State Education Department (NYSED); and

  • A Baccalaureate degree in Nursing or related health field from an accredited college or university; and

  • Two (2) years of experience as a Registered Professional Nurse.

  • Bachelors Degree

  • Life Support Certification(s): BLS, ACLS, PALS

How To Apply

If you wish to apply for this position, please apply online by clicking the "Apply Now" button.


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Accountable Care Manager

NYC Health Hospitals