RN - Care Manager Job
Full Job Title: RN, Care Manager
Job Number: 17007371
Facility: St. Anthony Hospital
Location: Oklahoma City, OK
Schedule: Full Time
- Work with designated clinical teams to provide care management of patients, including pre-visit planning and post-visit summary review. Assist patients in setting SMART goals for self–management, teaching them self-management tasks. Report abnormal findings to their physician team.
- Partner with physician leadership to define quality measure/outcome reporting process and develop protocols and point of care reminders using nationally recognized EBC measure/outcomes (recommend starting with three clinically important conditions).
- Manage assigned panel of chronic care (high acuity) patients by developing relationships with the patient and providing follow-up contact to ensure compliance with recommendations (i.e. medications, lab/x-ray, specialist visits, PCP visits, dieticians, CDE, etc.). Manage referrals to specialists, hospitalizations, ER visits, ancillary testing, and other enabling services.
- Provide telephone advice per protocol and handle urgent calls and emergent calls.
- Work with patient's care team to coordinate change readiness, needs assessment and develop an individualized treatment care plan. Collaborate with the patient, physician, and other care team members in assessing the patient's progress toward individual health care goals. Assess barriers when patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointments and work with care team to determine next steps.
- Serve as a resource to clinical staff and providers to establish quality goals using reports. Oversee the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams. Collaborate with payer Case Managers for additional services when appropriate.
- Develop a list of medical supply and community resources available to patients and maintains collegial relationships with the entities used most frequently.
- Work with appropriate parties to coordinate efficient consult request communication and consistent documentation of patient self-management measures which entails a mutually agreed upon care plan that is efficiently available to all and reporting of progress towards goals.
- Partner with consulting physicians, hospitals, ER and other frequently used healthcare resources to clarify roles, develop effective, efficient timely communication between PCP and these entities. Facilitate physician leadership to develop written agreements with consulting physicians and key facilities to define the roles and method of communication. Develop workflows and protocols within the PCP that ensure ER, hospital follow-up.
- Work with IT resources to facilitate registry reporting at the site & documentation of EBC in searchable fields.
- Perform other related duties as assigned that correspond to the overall function of this position.
- Licensed by the Oklahoma Board of Nursing as a Registered Nurse.
- Three (3) years of experience as a registered nurse.
- Current CPR (Healthcare Provider).
- Home care clinical experience preferred.
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