Nurse Care Manager

This is a fully remote position, open to applicants in Maryland.

📋 Description

• Act as a telephonic care management resource for clinical teams, integrating the care management program into physician practices.

• Establish quality measures, set goals, and create protocols and point-of-care reminders utilizing nationally recognized, evidence-based care quality standards.

• Enhance the effectiveness and efficiency of clinical practices and processes.

• Analyze medical records and both internal and external reports to pinpoint and investigate gaps in care.

• Formulate and execute practice-level strategies to address and remedy gaps in care.

• Identify patients who are suitable for care management.

• Optimize patients’ health, wellness, safety, self-care, satisfaction, and cost-effectiveness.

• Provide guidance to center nurses and health care team members, addressing urgent or emergent calls within the scope of practice.

• Proactively manage a designated panel of chronic care patients via phone.

• Evaluate patients’ physical and psychosocial needs, literacy levels, and obstacles.

• Educate patients and health care team members on preventive care and care coordination.

• Support comprehensive health assessments and adhere to payer contractual obligations.

• Coordinate change readiness assessments and develop tailored treatment care plans.

• Monitor and assess the effectiveness of care plans, making adjustments as necessary.

• Provide expert clinical advice to enhance patients’ overall wellbeing.

• Assist patients in establishing SMART self-management goals and instruct them on self-management tasks.

• Communicate abnormal findings to the care team.

• Encourage patient engagement and self-management practices.

• Document self-management measures, care plans, and progress towards goals.

• Collaborate with patients, families, caregivers, physicians, and care team members.

• Manage referrals, hospitalizations, emergency room visits, ancillary testing, medication reconciliation, and overall care coordination.

• Communicate recommendations and schedule follow-up visits with patients.

• Review provider documentation, follow up with patients, and log conversations and recommendations in the electronic medical record.

• Adhere to Patient First protocols for urgent and emergent calls.

• Anticipate the needs of chronic care patients and conduct pre-visit planning.

• Guide and motivate patients to utilize the Patient First patient portal.

• Facilitate communication between care team members and patients in decision-making processes.

• Employ motivational interviewing techniques to assess and address barriers to treatment goals.

• Oversee the development, acquisition, and implementation of patient self-management educational resources.

• Collaborate with external case managers and create lists of medical supplies and community resources.

• Work alongside physicians, hospitals, emergency rooms, and other health care resources to clarify roles and enhance communication.

• Advocate, facilitate, and intervene to ensure the implementation of treatment plans and continuity of care.

• Serve as a center staff nurse as required.

⛳️ Requirements

• Must be eighteen years of age or older.

• RN licensure is mandatory.

• Must be eligible for licensure in all states where Patient First operates.

• Current certifications in CPR, ACLS, and PALS are required.

• A minimum of three years’ clinical experience in medical/surgical, ER, critical care, and ambulatory care is preferred.

• Certification as a Case Manager or experience in Case Management and Primary Care/Patient-Centered Medical Home Care or environments coordinating care across multiple providers is preferred.

• Experience in telephonic triage, coaching, or care coordination is essential.

• Ability to thrive in a team-oriented environment.

• Highly organized with strong oral, written, presentation, and interpersonal communication skills.

• Demonstrated sound judgment, decision-making, problem-solving, and analytical skills.

• Extensive professional knowledge of comprehensive clinical assessment in the primary care population and chronic disease management.

• Understanding of the psychosocial aspects of chronic illness.

• Experience in quality improvement, quality and efficiency metrics, and data analytics is preferred.

• Proven ability to influence patients and providers positively.

• Experience with medically relevant care plan documentation and the capacity to develop and implement care plans.

• Proficient in active listening, critical thinking, social perceptiveness, active learning, and patient engagement instructional methods.

• Comfortable managing multiple tasks and continuously re-prioritizing as needed.

• Strong ability to delegate and exercise sound judgment while working with staff and providing medical care.

• Capable of effectively collaborating with all levels of administrative and professional personnel.

• Must maintain confidentiality in line with organizational guidelines and HIPAA regulations.

• Proficient in computer applications, including Microsoft Word, Excel, presentation software, and database management.

• Must be able to hear pages, bells, and phone systems.

• Must be capable of sitting, standing, and walking for extended periods, potentially 4 to 7 hours consecutively.

• Willingness to travel, including overnight stays, for meetings, conferences, and other events as necessary.

• Availability to work extended hours, including nights and weekends, as required.

• Bilingual skills are a plus.

🏝️ Benefits

• Sign-on Bonus.

• Health, Dental, and Vision insurance for employees and their dependents.

• Disability, Life, and Long-Term care insurance.

• Employee Assistance Program.

• Flexible Spending accounts.

• 401(k) Retirement Plan with employer matching.

• Paid Annual Leave.

• Volunteer Time Off Pay.

• Bereavement Leave.

• Emergency Leave Bank.

• Overtime Pay.

• Holiday Pay.

• Double time compensation for all holidays worked.

• Discounted medical treatment at any Patient First location for employees and their immediate family.

• Recruitment Bonus.