Manager of Care Management / RN Care Manager

Sign-On Bonus Available Relocation Assistance AvailableReceive 17% Weekday Nights, 26% Weekend Nights and 15% Weekend Day shift differentialsDepartment: COPE ClinicFull TimeShift: Days Position Summary:Coordinate all systems/services required for an organized, multidisciplinary, patient centered care team approach, and assure quality, cost-effective care for the identified patient population. Manage the course of treatment of patients, coordinating care with physicians, nurses and other staff ensuring quality patient outcomes are achieved within established time frames and with efficient utilization of resources. Conduct initial and ongoing assessments, initiate disease management protocols, determine and manage outcomes, ensure continuity of care through discharge planning, utilization of resources and analysis of variances. Function as a contact person for patient, family, health care team members, community resources and employees as necessary. Ensure adherence to Hospitals and departmental policies and procedures. Patient care assignment may include neonate, pediatric, adolescent, adult and geriatric age groups. PATIENT CENTERED MED - Adhere to and promote the core expectations of the Patient Centered Medical Home or Patient Centered Specialty Practice as applicableIDENTIFICATION - Identify appropriate patients within designated specialty area requiring patient case management interventions by utilizing established procedures including census review, risk screens, and referralDATA - Perform assessment, data collection, obtain, review, and analyze information in collaboration with the patient, family, significant others, health care team members, employers, and others as appropriateNEEDS - Assess the patient/family/significant others needs in relation to the medical diagnosis and treatment and resources; provide treatment options, financial resources, psychosocial needs, and discharge planning in collaboration with appropriate resourcesORDERS AND REFERRALS - Obtain necessary orders from physicians to initiate home health referrals, home infusion medications and supplies, oxygen and equipment; coordinate referrals for oxygen and equipmentREPORTS & RECORDS - Maintain computer-based tracking system and compile required reports and recordsCOLLABORATION - Develop collaborative relationships with other departments/services and community health care agencies facilitating and supporting quality care in area of clinical expertise; act as a resource on complex patient care activitiesGOALS - Assist the patient, family, significant others to set patient-centered goals for individual patient, family, and significant others in collaboration with physicians, staff RNs and other health care team membersPLAN OF CARE - Develop comprehensive multidisciplinary plan of care effectively utilizing tools and resourcesDISCHARGE PLANNING - Conduct timely discharge planning by anticipating patient needs in collaboration with physicians, staff RN's, and other health care team membersRESOURCES - Coordinate and evaluate the use of resources and services in a quality-conscious, cost effective manner and collaborate with appropriate providers to ensure effective, quality outcomesINTERVENTIONS - Monitor and evaluate short-term and long-term patient responses to interventions in collaboration with quality assurance and utilization review, maintaining interdependent follow-up as necessaryVARIANCE - Review variance from standardized protocols of care with health care team members and implement resolution strategiesTREATMENT CONFERENCE - Facilitate and/or participate in conferences providing ongoing evaluation of interdisciplinary dynamics, goals attainment and treatment managementassess patient/family knowledge, health status expectations, and locus of controlINFORMATION - Assist with development of activities and methods to ensure information is articulated and disseminated to appropriate members of the health care teamCONTINUITY OF CARE - Collaborate with the health care team to ensure continuity of patient care throughout all health care settings; promote effective communication among health care team members including the patient, family, and significant othersCARE PLAN - Incorporate recommendations and/or services of interdisciplinary team members in the care planCOMMUNICATION - Use interpersonal communication strategies with individuals as well as groups of patients, families, significant others, and staff to achieve expected outcomes and patient/family and health care team satisfactionDOCUMENTATION - Provide routine verbal and written documentation for the initial assessment and progress of the patient to other members of the health care team in a timely mannerORIENTATION - Participate in orientation, continuing education of staff RN's and other health care team members as appropriateQUALITY - Participate in continuous quality improvement activities by evaluating patient care systems that may include standards, protocols, and documentationCOMMITTEES - Attend meetings and represent department or Hospitals within Hospitals related committees or the community, as assigned by supervisorPATIENT SAFETY 1 - Follow patient safety-related policies, procedures and protocolsPATIENT SAFETY 2 - Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processesPATIENT SAFETY 3 - Identify and report/correct environmental conditions and/or situations that may put a patient at undue riskPATIENT SAFETY 4 - Report potential or actual patient safety concerns, medical errors and/or near misses in a timely mannerPATIENT SAFETY 5 - Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may "not seem right"document and communicate clinical findingsPATIENT CARE - (UPC and CPC Only) Write treatment plans; provide and coordinate nursing care of assigned patients; may facilitate group therapy and/or education sessions QualificationsProgram GraduateBachelor's DegreeNationally Accredited Nursing GraduateNursing Experience:Bilingual English/Keres, Tewa, Tiwa, Towa, Zuni, or Navajo Credentials:RN in NM or as allowed by reciprocal agreement by NM* CPR for Healthcare/BLS Prov or Prof Rescuers w/in 30 days Physical Conditions:and/or may require working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of materials is negligible. Minor Hazard - physical risks, dirt, dust, fumes, noise* Tuberculosis testing is completed upon hire and additionally as required Department: Registered Nurse