Registered Nurse (RN) - Care Manager Ambulatory Services (Rosecrans Clinic)
Company: Martin Luther King, Jr. Community Hospital
Posted on: June 25, 2022
If you are interested please apply online and send your resume
Under the general direction of the Site Administrator Ambulatory,
provides transitional and chronic care management; Identifies
eligible patients, advocates for enrollment, assesses patient needs
and barriers to care, then collaborates with the patient's care
team to tailor care plans, services, and resources to meet the
individual needs of the patient and caregiver;Remains skilled in
interpersonal communication and motivational interviewing to help
promote patient and caregiver engagement and self-management; Makes
routine contact based on patient complexity to help the patient and
caregiver. Develop goals, monitor outcomes, and evaluate patient
readiness for graduation from the program.The overall goal of the
RN Care Manager is to improve the health of populations, improve
the patient experience, reduce readmissions, reduce utilization of
higher cost healthcare, and promote patient and caregiver
engagement and self-management.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Coordinates with the Primary Care Providers, and all members of
the health care team to facilitate a strong transitional healthcare
pathway for the patient.
- Monitors patient's healthcare pathway to ensure adherence,
removes obstacles and identify progress toward desired care
outcomes; intervenes to overcome deviations in the expected plan of
care; reviews the care plan with patients in conjunction with the
direct care providers; interacts with involved departments to
negotiate and expedite scheduling and completion of tests,
procedures, and consults.
- Works with patients and their family members to develop a
personalized healthcare pathway that meets the individual's needs
on both a short term and long-term basis.
- Orients and educates patients and their families about the
healthcare pathway by meeting them; explaining the role of the RNCM
initiating the health plan; providing educational information in
conjunction with health care team related to treatments,
procedures, medications, and continuing care requirements.
- Identifies high-risk patient's to promote coordination of
services and to prevent readmissions or Emergency department
- Disease Management
- Assists in the management of patients with chronic diseases
following established protocols and systems for disease management
in collaboration with providers.
- Assesses patient learning needs and has the ability to develop
and implement individualized educational or care plans. Reviews,
evaluates and revises the plan on an ongoing and timely basis.
- Communicates with a multidisciplinary team (physicians, nurses,
therapists, social workers, etc.) as needed to assist with disease
- Develops self-management goals and monitors the progress of the
- Has the ability to oversee and assist the patient with referral
- Initiates disease-specific care conferencing as needed.
- Utilizes patient communication strategies, e.g. motivational
interviewing, to involve the patient in developing a plan of care,
goals or other specific measures pertinent to their health
- Assesses patient activation and readiness for change and uses
these to develop self-management goals.
- Participates in confidence level assessments or surveys of
patients to improve disease management care delivery
- Documents all disease management encounters using standardized
- Bachelor of Science degree in nursing preferred.
- Minimum of one (1) to three (3) years of hospital inpatient or
related experience required.
- Able to navigate and connect successfully with outside provider
networks (Health Plans, IPA's, and FQHC's).
- Current California Nursing license
- Certification in Case Management preferred.
C. Special Skills/Knowledge
- Bilingual language skills preferred (Spanish)
- Basic computer skills
- Current Basic Life Support (BLS) Required
Keywords: Martin Luther King, Jr. Community Hospital, San Clemente , Registered Nurse (RN) - Care Manager Ambulatory Services (Rosecrans Clinic), Executive , Alhambra, California
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