Coastal Medical is R.I.'s largest Primary Care practice, serving patients in R.I. and southeastern Massachusetts. An equal opportunity and affirmative action employer, Coastal Medical employs over 500 professionals in a variety of roles and functions including MDs, RNs, PAs, lab technicians, financials, IT, and medical billers.
The Nurse Care Manager will work on a multidisciplinary healthcare team in an outpatient primary care office. He/she will be part of a program charged with setting up a primary care medical home and administering health care in a new and innovative way. The Nurse Care Manager is responsible for providing comprehensive assessments, care coordinating services, disease education and self-management support to adult patients with 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 team meetings. This position reports to the Nurse Care Manager Coordinator.
Duties and Responsibilities
- Establish care management plans, interventions, treatment goals (including self-management goals) and contact schedules.
- Promote compliance with chronic 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.
- Complete initial patient assessment, including a comprehensive psychosocial, and functional assessment of the patient, including in the home setting if needed.
- 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 are up to date.
- Utilize a multi-disciplinary team approach to address opportunities to plan and coordinate care.
- Help arrange contact with ancillary personnel.
- Leverage EMR / chronic disease registry reporting to prioritize patient follow-up.
- Identify and utilize cultural and community resources.
- Ensure open communication regarding patient status with physicians, office staff and patients' families.
- Provide training to non-RN Quality Assistant and other practice staff as needed.
- Act as liaison to hospital, long-term care, specialists and home health representatives.
- Attend required training and collaboration sessions and practice team meetings as scheduled.
- Perform other related duties as required.
- Licensed RN, State of Rhode Island
Education and Experience :
- 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.
Other Skills/Abilities :
- Bachelor's degree in nursing
- Three (3) to five (5) year of experience in community health setting, public health, chronic disease management, community nursing, case management preferred.
- Experience working with primary care providers to coordinate care and disease management.
- Experience working with patients regarding their care coordination and disease management/education is preferred.
Work Environment :
- Ability to work independently and collaboratively to achieve goals.
- Highly organized and detailed.
- Exercise sound judgment and decision-making and the ability to assess and differentiate priorities.
- Excellent interpersonal skills and ability to work collaboratively with other staff members to get the job done.
- Excellent written and verbal communication skills.
- Able to maintain confidentiality with all aspects of information (including patient data) in accordance with the practice's philosophy and policy and state and federal regulations. Must possess the ability to handle the most sensitive and confidential matters with the utmost discretion.
- Proficiency with computer skills (i.e., Microsoft Word, Excel and Access, and Web-based applications).
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This position will work under normal physician office conditions and may also include visits to patients' home settings.
Physical Demands :
The tasks of this position are normally performed in a physician office setting. However, some duties will be completed sitting at a desk and using a computer. Mobility is required to attend meetings and give presentations. Additionally, reliability and a good attendance record are a necessity. The ability to travel to various locations in the state, typically via car is required. Regular lifting of up to 10 pounds and occasional lifting up to 25 pounds is expected.
Interested candidates should forward their resumes or CV’s to: email@example.com
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