Nurse Care Manager - Complex Case Management (NCM CCM)

To the nursing community - We see you!

Are you looking for a change? Is the stress of working in a chaotic environment getting to be too much? Would you like to get back to using your knowledge of chronic diseases, developing long term relationships with patients, providing education to help them manage their health, and working with interdisciplinary team members to improve care and coordination, all in an exceptionally engaging and rewarding environment with a regular schedule, weekends off, paid time off, and paid holidays? RIPCPC is the place for you!

We have an exciting opportunity for a Nurse Care Manager - Complex Case Management!

JOB SUMMARY

Under the supervision of the Nursing manager the Nurse Care Manager- CCM (NCM ) is responsible to evaluate and provide case management services for patients with complex medical and social needs. The NCM will have the opportunity to work on a multidisciplinary healthcare team in a primary care setting, including but not limited to the primary care provider, pharmacist, community health worker and the behavioral health specialist. The NCM is responsible for providing comprehensive screenings, assessment, care coordination services, disease education, and culturally sensitive, patient centered self-management support to patients with targeted chronic health conditions. The NCM will be integrated into the office-based healthcare team to promote patient-centered care, will have frequent contact with primary care providers and medical home team members, actively participate in multidisciplinary patient-centered care and team meetings.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES

• Retrieve monthly high-risk list and proactively outreach to enroll patients in complex case management
• Collaborate with Primary Care Physician (PCP) to prioritize patients identified for complex case management.
• Coordinate with the PCP office to leverage any opportunity to meet with a patient face to face before, during or after a regularly scheduled visit.
• Conduct home visits as necessary.
• Conduct a comprehensive assessment to evaluate a patient’s physical, functional, social, psychological, environmental, learning and financial needs.
• Identify and prioritize problems, goals and interventions designed to meet patient’s need and that consider the patient/caregivers goals, preferences and desired level of involvement in the case management plan.
• Create a patient centered care plan including goals, self-management goals, and interventions designed to address findings from the comprehensive assessment which demonstrate knowledge of and sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of the patient. Utilize interpreter services as needed.
• Provide education, information, direction and support related to care goals of patients as well as disease prevention and health promotion
• Implement and monitor the care plan to ensure the effectiveness and appropriateness of services, and adjust as needed
• Communicate on a regular basis (per established program requirements ( ex . NCQA) ) to evaluate patient’s progress toward goal achievement, including identification and evaluation of barriers to meeting or complying with case management plan of care, and systematically reassess for changes in goals and/or health status, and appropriateness for discharge.
• Support a patient’s transition between healthcare facilities by communicating with onsite case managers/ discharge planners and sharing current care management plans to facilitate care coordination, continuity of care and to avoid unnecessary readmissions.
• Critically evaluate case management plan and consider/implement innovative and customized options to help patients achieve goals as needed.
• Initiate communication and coordination of care with primary care physician, specialists, interdisciplinary care team, and other providers that are involved in the patient’s care as appropriate.
• Monitor relevant tests, labs and medications against standard of care guidelines and communicate any discrepancies with the PCP.
• Provide referrals to appropriate community resources, interdisciplinary care team member and facilitate access and communication when multiple services are involved; monitor activities to ensure that services are being delivered and meet the needs of the patient, coordinate services to avoid duplication.
• Act as a patient advocate and assist with problem solving and addressing any barriers to care or compliance with care plan.
• Maintain accurate patient records and patient confidentiality.
• Engage in professional development activities to keep abreast of case management practices and patient engagement strategies.

MEDICAL MANAGEMENT

· Participate and / or initiative prospective, concurrent, and retrospective case reviews / care conferences involving targeted patients with interdisciplinary team, Chief Medical Officer and payers as needed.

· Apply and document all relevant information following department policy guidelines.

· Maintain knowledge of operational policies, procedures and case management program components.

· Apply and document all relevant information following department policy guidelines

· Maintain knowledge of operational procedures and case management program policies and procedures.

· Promote chronic disease management concepts, health screening and preventive health initiatives when working with patients.

· Stay updated with the latest research, advancements and best practices in disease management to deliver evidence-based care.

PROGRAM MANAGEMENT

· Participate and promote appropriate performance improvement projects

· Develop, implement, and evaluate department initiatives and goals as assigned.

· Trouble shoot problems regarding operational and clinical procedures

· Participate in Quality Performance initiatives, the collection and analysis of data as needed

· Contribute to the development and implementation of condition specific evidenced based protocols.

GENERAL REQUIREMENTS

• Maintain accurate and up to date medical records and documentation.
• Perform quality work within deadlines and targets 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, department, and organization 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.
• Participate in initiatives that support the healthcare community in Rhode Island
• 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.
• A minimum of 2 years’ experience managing patients with complex medical and social needs
• Certified as a diabetic educator or in another chronic care area, or willing to obtain within 12 months of employment.

SKILLS AND TRAINING

• Flexibility and adaptability when implementing change
• Knowledge and skill in chronic disease management
• Able to initiate end of life conversations with patient’s providers, care givers if appropriate.
• Ability to work independently and collaboratively to achieve goals.
• Highly organized and detailed.
• Able to develop and manage relationships with interdisciplinary team members, patients, caregivers, family members, and providers
• Able to communicate priorities, and role if a PCP or others wants to engage you in activities outside of the defined job responsibilities
• Exercise sound judgment, critical thinking and decision making.
• Ability to multitask, assess and manage competing priorities
• Excellent interpersonal and relationship building 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).
• EMR experience preferred
• Maintain current licenses and certificates.
• Continue progressive professional development.
• Bilingual- Spanish speaking a strong asset, although not required
• Demonstrates compassion
• Active and unrestricted driver’s license

PHYSICAL REQUIREMENTS

· Prolonged periods sitting at a desk and using a computer.

· Able to sit/ stand/ walk for long periods of time – including entering and exiting offices and various healthcare buildings – including RIPCPC premises and partner practices.

· Workspace / Environment will differ depending on provider office setting – some may contain stairs without elevators or ramps.

· Must be able to travel to and from home, RIPCPC premises, and provider offices.

· Must be able to lift 15 pounds at times.

What RIPCPC does...

Rhode Island Primary Care Physicians Corporation (RIPCPC) is a multi-specialty Independent Practice Association (IPA) that has been implementing innovative quality improvement models since 1994. We are a population health management organization that focuses on improving outcomes for our physician members’ patients.

Our dedication to improving the care delivery system is demonstrated through our commitment to the National Committee for Quality Assurance’s Patient-Centered Medical Home (PCMH) model. A patient centered approach to practicing medicine enhances quality, improves access and implements advanced care coordination strategies. RIPCPC has implemented more PCMH’s than any other organization in Rhode Island.

In addition to the proliferation of the PCMH, our latest and most significant initiative is focused on shaping a virtually integrated health care system with Care New England. This joint venture has led to the creation of an Accountable Care Organization (ACO), Integra, Rhode Island’s first partnership between a physician organization and a hospital system. Integra’s unique ability to coordinate care system wide enables us to deliver a care experience unmatched in Rhode Island.

Our Mission: Deliver the highest quality of health care and the best patient experience in the State of Rhode Island.

Rhode Island Primary Care Physicians Corporation is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

Job Type: Full-time

Pay: $80,000.00 - $90,000.00 per year

Benefits:

• Continuing education credits
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Health savings account
• License reimbursement
• Life insurance
• Mileage reimbursement
• Paid sick time
• Paid time off
• Retirement plan
• Vision insurance
• Wellness program

Schedule:

• Monday to Friday

Work Location: Hybrid remote in Cranston, RI 02920