Nurse Care Manager

Aunt Martha’s Health and Wellness boldly commits to supporting the well-being of our communities, ensuring equity in access and delivering exceptional care inspired by a culture of innovation. We are taking a responsible approach to creating environments that allow us to do what we do best—provide healthcare and wellness. As a part of our commitment to health and safety, COVID-19 vaccines are required for all employees, as well as all newly hired employees. We require documentation upon hire.

SUMMARY:

Under the direct supervision of the Care Coordination Nurse Supervisor, the Nurse Care Manager performs general functions including monitoring and coordination of the healthcare needs of patients to ensure appropriate delivery of healthcare services. The Nurse Care Manager ensures high and medium risk patients receive a comprehensive risk assessment, working care plan, and health education to include but not limited to appropriate ED utilization. The Nurse Care Manager is responsible to work with health center staff including primary care providers as well as clinic staff that provide care and services to Aunt Martha’s patients. The Nurse Care Manager provides excellent quality care, positive customer service, the maintenance of an efficient and safe environment of care. Demonstrates superior customer service skills and has the ability to function in a multi-tasking, multiple priorities environment, while maintaining accuracy and attention to detail.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Maintain patient confidentiality at all times per the policies and procedures.
• Maintain ethical behavior at all-time per the policies and procedures.
• Responds to internal and external customer needs in a positive manner, utilizing principles of the AIDET model; exceeding their needs and expectations and providing the highest quality service to ensure the best possible outcomes.
• Master the electronic health record system, Athena, to appropriately document patient data and information, in addition to managing databases with outcomes data. Maintains accurate and timely documentation in the EMR.
• Collaborate with care coordination and clinic staff, other Aunt Martha’s division programs and external agencies or organizations to ensure patient’s medical and social needs are met.
• Performs all required and appropriate assessments for care-managed population. This includes physical and psychological assessments as appropriate. The assessment includes a systematic and pertinent collection of data about the health status of the patient.
• Completes all initial and ongoing assessments/documentation within indicated time frame as specified by program and/or supervisor.
• Conducts review/update of established care plan for high risk patients within 30 days of prior care plan review/update.
• Prioritize patients according to risk stratification, need and required follow up.
• Formulates and implements a care management plan for high risk patients that addresses the patients identified needs by assessing the patient/family needs, issues, resources and care goals; determining the choices available to individual patients; educating the patient/family on the choices available.
• Establishes a care management plan that is mutually agreed upon by the health care team and the patient/family. Plans will contain specific mutual self-management SMART goals, objectives, and interventions.
• Identifies and effectively utilizes community resources to meet the needs of patients/families.
• Initiates and maintains communication and collaboration with physicians, social workers, care team leaders, staff nurses, other care giving disciplines, and patients/families to develop, implement, and evaluate a transition plan of care for each patient.
• Identify patients at risk of admission or emergency room utilization, outreach to and link them with appropriate resources to prevent any unnecessary care.

QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

EDUCATION and/or EXPERIENCE:

• B.S. Degree in Nursing or A.A. Degree with 2 years’ experience working in the healthcare field preferred
• Experience in working with Microsoft Office programs essential; adept at data entry
• LPN/LVN license with 3 years’ experience in healthcare field

OTHER QUALIFICATIONS:

Current driver’s license

Current auto insurance

Ability to work late evening hours, weekend hours, and scheduled holidays, as needed

Aunt Martha’s is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.