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Rhode Island Primary Care Physicians Corporation

Nurse Care Manager

JOB SUMMARY

The Nurse Care Manager will have the opportunity to work on a multidisciplinary healthcare team in a primary care setting. The Nurse Care Manager is responsible for providing comprehensive screenings, assessment, care coordination services, disease education, and self-management support to patients with targeted chronic health conditions. The Nurse Care Manager will be integrated into the office-based healthcare team to promote patient-centered care, frequent contact with primary care providers and medical home team members, and actively participate in multidisciplinary patient-centered care, frequent contact with primary care providers and medical home team members, and actively participate in multidisciplinary patient-centered team meetings.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES

  • Leverage EMR / chronic disease registry reporting to prioritize patient outreach and follow-up.
  • Complete initial patient assessment, including a comprehensive medical, psychosocial, and functional assessment of the patients.
  • Provide detailed education about patient’s specific chronic illness, including the pathology, signs and symptoms, complications, and medications used in treatment.
  • Assure that screening tests and immunizations are up to date.
  • Utilize a multidisciplinary team approach to address opportunities to plan and coordinate care.
  • Establish care management plans, interventions, treatment goals – including self-management goals, and contact schedules.
  • Promote compliance with care plan.
  • Coordinate care and communicate with multiple providers.
  • Review test results and track outcomes.
  • Review patient compliance issues.
  • Work one-on-one with patients.
  • Arrange group visits when necessary.
  • Identify and utilize cultural and community resources.
  • Ensure open communication with appropriate office staff.

GENERAL REQUIREMENTS

  • Perform quality work within deadlines with or without direct supervision.
  • Share best practices among all teams, serve as a medical home advocate, mentor and lead by example to support a positive work environment, and encourage other staff to do the same.
  • Represent the practice in a positive manner to all patients and all applicable external clients.
  • Bring issues to the appropriate manager(s) in a timely manner for resolution.
  • Perform other related duties as assigned.

 

MINIMUM QUALIFICATIONS

EDUCATION AND EXPERIENCE

  • Licensed RN, State of Rhode Island.
  • 3-5 years of experience in community health setting, public health, chronic disease management, community nursing; case management preferred.
  • Certified as a diabetic educator or in another chronic care area, within 12 months of employment.
  • Experience working with primary care providers to coordinate care and disease management.
  • Experience working with patients regarding care coordination and disease management / education is preferred.
  • Bilingual- Spanish Speaking

SKILLS AND TRAINING

  • Ability to work independently and collaboratively to achieve goals.
  • Highly organized and detailed.
  • Exercise sound judgment and decision making.
  • Ability to assess and differentiate priorities.
  • Excellent interpersonal skills.
  • Excellent written and verbal communication skills.
  • Ability to maintain confidentiality in accordance with HIPAA.
  • Proficiency with computer skills (i.e., Microsoft Word, Excel and Access, and Web-based applications).
  • Maintain current licenses and certificates.
  • Continue progressive professional development.

Job Type: Full-time

Please send Resume to:

Darlene Dorocz, ADN, RN, CDOE

Director of Nursing

Rhode Island Primary Care Physicians Corporation

Phone (401)654-4000 x103

Fax: (401) 654-4001

Email: ddorocz@ripcpc.com

Our Mission

The mission of the Care Transformation Collaborative is to lead the transformation of primary care in Rhode Island in the context of an integrated health care system; and to improve the quality of care, the patient experience of care, the affordability of care, and the health of the populations we serve.