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