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RN Care Manager PCT, the Clinic
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- We're going beyond basic care to health programs integrated across the entire continuum of care.
- Therefore, this position integrates palliative approaches to care in our primary care setting.
- This role works closely with physicians, social workers, other specialty teams (like palliative care, oncology, etc.)
- This complex work benefits from a nursing approach that is focused on creative problem solving and big-picture awareness rather than short-term solutions and reliance on strict rubrics.
- Care Management activities include early identification of high-risk patients, concerted planning involving physicians and mid-level practitioners, monitoring of services provided by outside physicians, home health, DME, and other providers; monitoring emergency department use as well as identifying opportunities to decrease emergency department utilization and other elements of care utilization
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