PeaceHealth is seeking a RN Complex Care Manager Outpatient - Family Practice for a Full Time, 1.00 FTE, Day position.
Must be fully vaccinated for COVID-19 including 2 doses of a 2-dose series or 1 dose of a 1-dose series plus 14 days beyond the final dose prior to start date.
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Oversees and evaluates coordination of integrated population management across selected populations to improve clinical and financial outcomes. Develops care management programs addressing a wide scope of health care needs and conditions in partnership with physicians, health care professionals and patients. Identifies, coordinates, and case manages a panel of clinically high-risk complex patients and provides oversight for caregivers who manage patients at moderate or low risk.
- Accountable for development and continuous evaluation and assessment of population management programs, tools and delivery of care coordination services. Collaborates with system and regional leadership to optimize processes and metrics.
- Risk-stratifies patients according to protocols, assesses patient data, and works within interdisciplinary care team to assess patient’s physical, cognitive, emotional and behavioral status as well as social and financial support systems.
- Works with patients and families to create and implement a care plan that meets identified needs and incorporates services that improve outcomes. Adjusts care plan to patient activation and risk levels through ongoing monitoring of patient.
- Delegates and oversees the care management of lower-risk patients as well as routine chronic disease population management tasks to assigned caregivers.
- Tracks, evaluates, and provides oversight for transitions of care, synchronizing “warm handoffs” between the clinic and hospitals, emergency departments or care facilities. Facilitates and ensures the sharing of information across people, functions, and sites.
- Demonstrates leadership, mentorship and teamwork within dedicated care teams including clinicians, chronic disease care coordinators, medical assistants, pharmacists, social workers and others.
- Performs other duties as assigned.
- Graduate of an accredited school of nursing required.
- BSN/MSN preferred
- Minimum of three years of clinical nursing experience in an ambulatory or clinic setting required.
- Skill and proficiency in applying highly technical principles, concepts, and techniques. Such proficiency is usually acquired through completion of a bachelor’s degree in nursing; any equivalent combination of education, training, and/or experience that fulfills the requirements of the position will be considered.
- Care Management or Care Coordination experience preferred.
- Utilization management/quality management experience preferred.
- Current Registered Nurse licensure in the state in which nurse will be practicing.
- Current BLS (Basic Life Support) certification required at date of hire.
- ACLS may be required within a standard grace from hire or transfer period, as specified in the PeaceHealth Policy Resuscitation Training Completion Requirements, or upon hire.
- Care Management Certification within two years of hire preferred.
- Basic knowledge of statistics
- Interpersonal skills to obtain and interpret information appropriate to patients’ needs and age as required for assessment range of treatment, and patient care.
- Demonstrated ability to promote positive interpersonal relationships and patient/family centered work environment.
- Demonstrated ability to delegate and supervise the performance of tasks.
- Demonstrated ability to provide training, mentorship and development to clinic staff.
- Basic computer skills including MS Office applications
- Effective prioritization skills
PHMG - PHYSICAL/COGNITIVE REQUIREMENTS:
- Work requires normal amounts of physical effort up to 33% of the time.
- Ability to lift objects weighing 30 lbs. or less.
- Work requires frequent exposure to minor cold, heat, poor ventilation or sharp instruments. Reasonably anticipated exposure to blood and body fluids once per month or more.
- Job duties frequently require intense concentration and attention to detail (34-65% of work time).
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For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state, or federal laws.