Care Management RN – Lead

The Lead Registered Nurse Care Manager provides effective transitional and chronic care management for an assigned panel of high-risk patients with chronic conditions, as well as those with complex psychosocial needs. This role is responsible for the active management, including transition management, of patients as the liaison between members of the patients care team, including specialty offices. The Lead Registered Nurse Care Manager works to improve patient health, wellness and autonomy through advocacy, communication, education, identification of service resources, and service facilitation. This role requires the ability to apply the nursing process (assessment, diagnosis, planning, implementation, and evaluation) to all care provided.  

The Lead Registered Nurse Care Manager will deliver nursing care services to Neighborhood Health Center (NHC) patients both in person at a Primary Care Clinic setting or via the telephone from either the administrative office or from home.

Essential job duties:

  • Actively participates in the development of care management standards and care delivery models within clinics and across NHC primary care.
  • Able to define and implement Care Management and Care Coordination services at NHC .
  • Utilizes evidenced-based models, such as Coleman’s “Four Pillars of Care Transition” or other identified model.
  • Develops knowledge of CMS Chronic Care and Transitional Care Management Services.
  • Oversight of RN Care Management Program, including development, implementation, and auditing of key workflows.
  • Supports colleagues with resources, guidance, and hands-on collaboration as necessary.
  • Monitors and reports on Care Management Key Performance Indicators to Nursing Manager, Director of Nursing and Clinical Services, and Clinic Manager.
  • Daily work includes compiling recent patient hospital admissions and discharged census in preparation for weekly team huddle.
  • Assists and promotes the identification of the targeted patient population who will benefit from care management.
  • Performs hospital and emergency department follow up to ensure safe transitions of care for patients.

Education and experience:

  • This position requires an Associate Degree in Nursing with at least 2 years of nursing experience; a Bachelor of Science in Nursing degree is preferred.
  • This position requires completion from an accredited school of nursing.
  • 2 years of previous Nurse Case Management experience is required.
  • 1-3 years related experience and/or training in the FQHC, or primary care field, is preferred.
  • Ability to fluently speak, read, and write in Spanish is highly preferred.
  • Previous EPIC or EHR experience is preferred.
  • Certificate in community and/or hospital case management, such as Certified in Care Coordination and Transition Management (CCCTM), Certification in Managed Care Nursing (CMCN) or Nursing Case Management Certification (CMGT-BC), is preferred.

APPLY NOW

To apply for this job email your details to zilkek@nhcoregon.org