Care Manager Registered NurseHudson, NC

Care Manager Registered NurseAt Hopscotch Primary Care, we believe great healthcare should be accessible to all people across all communities. Today, almost 20% of Americans live in a rural community, yet only 11% of physicians practice in those same communities. We are on a mission to transform healthcare in rural America. We provide high-quality primary care tailored to meet the needs of our patients through our robust care model and comprehensive care team, delivering care in our clinics, and across settings, and wrapping resources around the patients who need them most.Our patients and the care teams who serve them sit at the center of everything we do at Hopscotch. Hopscotch Primary Care takes a team approach to serve patient needs and provide the best care possible. Our goal is to provide the care each of us would want for ourselves or for our family members, in the right setting, and at the right time.Today, we are serving thousands of patients in our value-based care model and the number is growing every day. If you want to bring your experience, skill and passion to make a lasting impact in healthcare, we'd like to meet you.About the RoleAt Hopscotch Primary Care, we take a team approach to serve patient needs and provide the best care possible. Our goal is to provide the care each of us would want for ourselves or for our family members, in the right setting and at the right time. The Hopscotch Care Team is responsible for delivering high-touch, high-quality care to patients, including coordination of care across different physicians and within the healthcare system.As a Care Manager Registered Nurse, you will play an important role in the care for our patients by achieving positive patient outcomes and by managing quality of care across the continuum of care. This professional will partner across the care team to develop effective plans of care and achieve high levels of communication and coordination for care planning and care delivery. Establishing strong and trusted relationships across the care team and with patients, their families and caregivers, other providers outside Hopscotch and those within the community will be critical to enabling success.This role is based in Hudson, NC.What You'll DoSpecific responsibilities for this role include but are not limited to:Manage end-to-end case management services to a defined panel of risk-stratified patients:Relationship Development and Navigation of Healthcare Ecosystem:Establish and maintain trust and strong relationships across care team, patient/family/caregiver and broader provider and community ecosystem to enable full spectrum care managementBuild relationships across provider community and leverages data/team insights to refer care to preferred providersManage and plan for transitions of care, discharge and post discharge follow-up for patients transitioning to/from a hospital, ED, or SNFCare Coordination, Planning and Collaboration:Collaborate with clinical staff in the development and execution of the plan of care and achievement of goals. Report variations to the care team and take actions as appropriate.Coordinate the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting. Coordinate the patient care, discharge and home planning processes with hospital case management departments, and other healthcare facilitiesCommunicate proactively with patient/family, care team and provider partners around needs, updates and actions required to enable patient care and outcomesAddress advanced care planning including treatment goals and advanced directivesPatient Support and Advocacy:Actively advocate for the patient and serve as a resource for the family to maximize their ability to make informed, timely decisions and to enable patient outcomesProvide family education, identify post-hospital needs and coordinate planning to ensure needs are metSupport best practices and protocols for care management and demonstrate commitment to clinical excellence, quality and compliance:Direct and participate in the development and implementation of patient care policies and protocols to provide advice and guidance in handling unusual cases or patient needsSupport training and education around care management and related topics, including the development of new resources to support best practices and processesInvestigate and report adverse occurrences, and perform staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare deliveryAdhere to Hopscotch Code of Conduct and proactively live the Hopscotch valuesAbout YouYou would be a great fit for this position if you have:An associate's degree in Nursing (required)A Bachelor of Science Degree in Nursing (BSN) or an RN with a bachelor's degree in a related clinical field (preferred)A minimum of 2 years of clinical work experienceA valid, active Registered Nurse (RN) license in State of employmentA minimum of 1 year of utilization review or case management (required)Certification in Case Management (preferred)Experience utilizing electronic medical record systems and proficiency with technologyKnowledge of the healthcare system, including community health services, social support services and providers (specialists and hospital systems)Knowledge of regulatory requirements, including Medicare, Medicaid, FDA, DOT, OSHA, state requirements, health care accreditation, and professional standards of practice (preferred)Ability to travel locally and regionally, as neededUS work authorizationAdditional skills and capabilities required:Strong interpersonal and communication skills, verbal and writtenHigh emotional intelligence and strong collaboration skills working with diverse groupsSkill with motivational interviewing, behavior change, health promotion, and coachingHigh attention to detail, organization, coordination and planning skillsSolid problem solving and critical thinking skillsA proven ability to learn complex topics quickly and put knowledge into actionFrom a cultural perspective, you:Create a culture of excellence, by bringing your best and encouraging the same from those around youPut service to patients first and encourage the same of those around youTake ownership and accountability for your work and for delivering results for patientsAssume the best in others and bring solutions to challenges with a focus on moving forward togetherShow an active commitment to the team by collaborating and communicating proactivelyDemonstrate a dedication to continuous improvement, in clinical and cultural settingsAt Hopscotch Primary Care, we embrace diversity, invest in a culture of inclusion and positivity and encourage all to apply to join our team. You will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.