Nurse Care Manager - Family Practice At Parkview

Parkview Adventist Medical Center Brunswick , ME 04011

Posted 4 weeks ago

Overview

Care management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates plans of care designed to optimize patient's health care across the care continuum. It includes empowering patients to share in the decision making process, exercise their options for treatment and access the services appropriate to meet their individual health needs. The role of Care Manager requires one to have advanced clinical knowledge, as well as highly developed communication and interpersonal relationship skills.

Responsibilities

  • Collaborates with physician and practice staff in identifying appropriate patients for care management

  • Meets with all patients identified for the MCMG RN Care manager- assess, engage in setting goals, and follow-up as appropriate

  • Meets with patients newly diagnosed with a chronic disease to ensure patient understands their disease process (medications, nutrition, exercise)

  • Documents plan of care in Centricity so all members of the team understand the plan and work together with the patient to achieve outcomes

  • Provides patient with plan of care and goals

  • Uses teach-back methodology to educate patients/families about medications, side effects and key concepts for disease management

  • Utilizes motivational interviewing skills to promote and encourage behavior change.

  • Provides clinical triage support to MA's and office when calls require an RN's expertise

  • Mentor other clinical staff by leading daily huddles and regular staff meetings, acting as a resource for clinical questions, and providing/coordinating ongoing education sessions for staff

  • Takes the lead role on the care management team by facilitating regular IDT care management meetings (at least bi-weekly)

  • Conducts care management assessments (using team developed tool) to determine where patient needs are best met (CCT, PHO, BHI, Social Work)

  • Tracks the number of patients actively engaged in care management, including who the primary care team is

  • Contacts patients after any ED/Hospital visit to identify patient is safe and there is little/no risk of a return visit. Provide education where needed and determine if the visit was avoidable/unavoidable

  • Tracks the number of patients seen in the ED, including whether the visit was avoidable/unavoidable

  • Actively participates in hospital case management meetings on a regular basis

  • Actively participates in continuing education opportunities related to care management and transition of care

  • Develops relationships and works with community partners (CHANS, CCT, Senior Spectrum, Tobacco Help Line, Mid Coast Health line, Center for Weight Loss) to break down barriers that impede patient progress toward goal achievement.

Qualifications

  • RN Degree. Must be willing to commit to BSN program enrollment within 1 year of hire.

  • 2 years clinical experience

  • Current Maine licensure.

  • Current Basic Life Support (BLS) certification

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Parkview Adventist Medical Center