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Heart Failure Care Manager - RN

Charlotte, NC, United States
Job ID: 65947
Job Family: Nursing
Status: Full Time
Shift: Day
Detailed Shift and Schedule: Monday - Friday 8-5
Job Type: Regular
Department Name: 26511035132045-Vascular Service

Overview

FLSA Status: Nonexempt Original Date: June 2019 Last Revision:

JOB SUMMARY: Utilizes the care management process as an integrated member of a multi-disciplinary care team. Works closely with adult patients, pediatric patients/family, primary care physician, and the health care team to help ensure that patients receive comprehensive and coordinated care. Serves as an integral member of the Care Team, conducting comprehensive clinical assessments, developing a patient-centric care plan, and engaging the patient and family through coaching, with a focus on preventing admissions, readmissions, and adverse events. Assesses, plans, implements, coordinates, and evaluates the plan of care in partnership with the patient/family and other members of the health care team. Communicates and collaborates with the patient?s primary and specialty healthcare providers to provide well-coordinated care. Ensures that patients receive care that is respectful of and responsive to individual patient preferences, needs, and values.

EDUCATION/EXPERIENCE: Graduation from an accredited School of Nursing (RN). One year of nursing experience in a clinical setting required. Experience in case management and/or care coordination preferred.

LICENSURE, CERTIFICATION, and/or REGISTRATION: Current licensure as a Registered Nurse (RN) in the State of North Carolina. Valid North Carolina driver?s license. CCM (Certified Case Manager) preferred or willingness to obtain certification within the first 12 months of hire.

ESSENTIAL FUNCTIONS: 1. Utilizes targeted reports and real-time referrals to identify patients who may benefit from care management services. 2. Performs patient assessments to identify and prioritize patient?s medical and behavioral health conditions, and health system and social determinant needs while also identifying patients? knowledge gaps. 3. Completes in-home safety assessment and addresses specific safety risks, as required. Establishes goals that are patient specific and identified as part of the patient?s self-management goals. Develops patient-centered care plans with the patient/family that considers medical, mental, emotional, spiritual, social, cultural, relational, contextual and environmental aspects, providing all information to the PCP. Sets an appropriate timeline for achieving identified goals. Updates the patient care plan as changes in status occur and communicates with the PCP and other members of the treatment team, as indicated. 4. Coordinates all aspects of care for patients through the continuum, including physical health, behavioral health, and social needs. Coordinates transitions of care between clinical settings. Conducts medication reconciliation and provides education, and consults with pharmacist, as needed. 5. Facilitates communication and collaboration among payors, providers, and community agencies to meet the needs of patients/families and promote continuity of care. 6. Develops trusting, professional, caring relationships with patients and families, engaging respectfully and with utmost attention to service. 7. Considers the developmental needs of all ages of patients throughout the continuum of life and adjusts care to those needs. Provides phone calls to reinforce education, ensures movement towards reaching goals, and promotes self-management, while utilizing identified teaching materials and evidence based best practices. Utilizes telemonitoring equipment to support wellness when indicated and as available. Documents assessments, screenings, tasks, interventions, goals, care plans, and medication management in the appropriate database, per department policy and national accreditation guidelines. 8. Acts as a resource to staff, works on a case-by-case basis to coach and mentor on techniques, and approaches to management of psychosocial issues in a high-risk population. Provides short-term crisis intervention support and education for patients, as needed. Makes appropriate referrals for ongoing needs. 9. Delegates tasks and oversees the work of a Care Management Associate who assists in the management of patients. Maintains collaborative, team relationships with peers and colleagues, and helps foster a positive work environment, including working collaboratively with Emtiro staff and all affiliated organizations. 10. Demonstrates the ability to function in a professional setting through active participation in a professional care team environment. This includes participating in team meetings, adherence to care coordination standards and principles, professional development and growth, autonomous practice, acknowledgment of accountability for actions, and critical thinking. 11. Maintains good understanding of chronic disease, behavioral health diagnoses, evidence-based treatment and management, motivational interviewing techniques, and applies these principles in the care management services provided to patients. 12. Completes annual trainings and competencies. Attends staff meetings and continuing education programs related to program goals. 13. Embraces innovation and adapts to various technology platforms. 14. Commitment to continual growth as an individual and as a member of an innovative and growing organization, including embracing new initiatives.

SKILLS & QUALIFICATIONS: Excellent oral, written, and interpersonal communication skills Self-motivated, self-directed, and ability to work independently with minimal supervision Conflict resolution skill Promotes collaborative work atmosphere with effective leadership, teaching, and coaching Demonstrates ability to work well with people of various ages, backgrounds, ethnicities, and life experiences Robust understanding of management of chronic health conditions and population management Knowledge of behavioral health and wellness issues Must have experience with spreadsheet and database program applications Ability to accept and incorporate critical comment Able to work in a continuously changing work environment Attention to detail

WORK ENVIRONMENT: Clean, comfortable, office setting Occasional evening or weekend hours Local travel

PHYSICAL REQUIREMENTS: Amount of time spent performing the following activities: 0% 35% 65% to to to 35% 65% 100% N/A Activity X Standing X Walking X Sitting X Bending X Reaching with arms X Finger and hand dexterity X Talking X Hearing X Seeing Lifting, carrying, pushing and or pulling: X 20 lbs. maximum X 50 lbs. maximum X 100 lbs. maximum

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