Two to three years college level courses/Associate’s Degree/Diploma in Nursing, Bachelors Degree in Nursing preferred. New Mexico RN License required. One to three years experience in ambulatory care Requires detailed knowledge of patient care in terms of what and how work is to be done as well as why it is done, this level includes interpretation of data. This staff member must demonstrate knowledge of the principles of growth and development over the life span of patients served.
Primary Job Functions
Summary of major job functions The Care Manager pro-actively manages the care for patients along a continuum by facilitating collaborative care between patient, family/support system, physicians, and other ancillary departments/members of the primary care team
Key job accountability # 1 • Assessment of an identified patient population based on symptoms and medical history
Key job accountability # 2 • Development of a plan of care based on preventative care needs, using standard based practice guidelines.
Key job accountability # 3 • Collaborates with patients to update problem list, current medication list and coordinates visit plan
Key job accountability # 4 • Monitor’s patient “open loops” e.g. missed appointment, non-compliance
Key job accountability # 5 • Serves at patient advocate. Serves as communication link between Inpatient Care Manager, HHC Care Manager and PHP Case Manager
Key job accountability # 6 • Documentation within scope of practice.
Key job accountability # 7 Seeks opportunities to develop one’s self and colleagues by mentoring, advising and guiding fellow employees
Key job accountability # 8 Coordinates, provides and documents patient education plan using standard based practice guidelines. Interacts effectively with customers, providing instruction and information, both written and verbal, as appropriate. Validates patients understanding of care/intervention recommendations
Key job accountability # 9 Evaluates nursing care, seeks to improve process and is through and accurate in completing work.
Key job accountability # 10 Communicates with the provider team and other community health related persons in order to coordinate care plan
Key job accountability # 11 Supports the Care Team Associates as a member of the Primary Care Team
Presbyterian Healthcare Services - 19 months ago