Position Description:
A registered nurse who is part of the primary care practice team and is responsible for organizing, coordinating, and providing care coordination and care management services to patients within the practice. The Health Risk Assessment (HRA) Nurse Case Manager acts as an integral part of the primary care team and is responsible for ensuring that the primary care physician (PCP) and practice team maintains a central role in coordinating and managing the care of vulnerable patients. The HRA Nurse Case Manager is responsible for a panel of patients. S/he will work with a team including behavioral health, case management, and primary care to establish goals and a plan of care for each complex patient. The RN CM is the point person for completing HRAs and may work with other team members to make sure that services are coordinated and communicated between all team members and the patient’s primary care provider (PCP).
Essential Functions:
· - Assuring that HRAs are completed within the allotted timeframe(s).
· - Assisting the care team with keeping the patient/family informed about the plan of care and ensuring they are involved in decision-making about that care, as needed.
· - Identifying and managing the patient’s primary driver (reason or problem that caused the hospitalization or ER visit).
· - Comprehensively assessing patient’s physical, mental, and psychosocial needs.
· - Maintaining a registry of completed HRAs.
Primary Objectives:
· - Review HRA patient lists to identify patients that are at risk for health deterioration, sentinel events, and/or poor outcomes.
· - Develop a tracking system for HRA completion.
· - Complete assigned number of HRAs within the specified timeframe.
· - Coordinate care with specialists and other healthcare providers (referrals, testing, procedures, etc.), as needed.
· - Communicate and affirm patient needs, plan of care, and changes in status with the PCP, team, and patient/family, as needed.
· - Improve utilization and disease-related outcome measures in the patient population.
· - Integrate the patient/family into care coordination and care management planning and communications, assuring they are informed and supported in decision-making.
Required Experience, Education, Skills, and Working Conditions:
· - Experience in case management (preferred), home health care nursing, hospital nursing, or primary care.
· - Education: Registered Nurse (minimum)
Skills:
· Comprehensive nursing assessment, problem identification and care plan development
Screening for developmental issues, depression, other psychological conditions, and frailty
· Behavioral strategies including motivational interviewing and self-management support
· Relationship building with patients, staff, and providers
· Documentation in a computer system
· Computer skills including Microsoft Excel, Word, and PowerPoint
· Working conditions: Remote
Job Types: Full-time, Contract
Pay: From $50.00 per hour
Expected hours: 40 per week
Benefits:
Schedule:
- 8 hour shift
- Monday to Friday
Experience:
- Health Plan: 1 year (Required)
- Case management: 1 year (Required)
License/Certification:
Work Location: Remote
