Primary Care Nurse Case Manager / Care Coordinators - Part-Time Days
Primary Care Nurse Case Manager / Care Coordinators - Part-Time Days
Posted 7 days ago
SENIORITY
Senior
About the role
- Responsible for developing a comprehensive, individualized plan of care and targeted interventions.
- Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
- Continually monitors patient/family response to plan of care and revises the care plan as indicated.
- Maintains comprehensive medical record documentation on the appropriate information systems and databases using required documentation and billing guidelines.
- Utilize electronic health record (EHR) activities to manage preventative care for patients.
- Proactively reach out to patients most in need of care by utilizing EHR reporting tools.
- Manage the care of high risk patients using EMR patient outreach tools, which may include but not limited to: completing appropriate assessments, creating and tracking patient goals, and managing health maintenance
- Assist in the development of adequate workflows to ensure patient care needs are met.
- Collaborates with Providers, patients, families, and members of health care teams across a continuum of care settings and the community.
- Fosters a team approach and includes patient/family as active members of the team.
- Takes the lead in ensuring the continuity of care which extends beyond the clinic boundaries.
- Serves as liaison to acute care hospitals, specialists, post-acute care services and community agencies.
- Provides follow-up with patient/family when patient transitions from one setting to another.
- Completes timely post-hospital follow-up activities including review of discharge instructions, condition specific education, coordination of care, and assists in problem solving barriers.
- Identifies targeted, rising risk and high risk populations within clinic site(s) per Provider referral, risk stratification, registries, and/or patient lists.
- Assesses the health care, educational, and psychosocial needs of the patient/family.
- Uses standardized assessment tools such as Nurse Case Management assessments and health risk assessments.
- Develops individualized patient/family education plans. Instructs and counsels patient/family regarding acute/chronic illnesses, the use of prescribed treatments and medications, care coordination.
- Provides patient self-management support with a focus on empowering the patient/family to build capacity for self-care and integrate health promotion into their lifestyle.
- Works with clinic and leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management.
- Demonstrated written and verbal communication skills. (High proficiency)
- Ability to apply the nursing process to acute patient care to achieve outcomes. (High proficiency)
- Current knowledge of the healthcare environment, including community resources and financial systems. (High proficiency)
- Working knowledge of basic computer programs such as word, excel. Knowledge of smart phone use. (High proficiency)
- Registered Nurse - State Licensure and/or Compact State Licensure Upon Hire Required.
- Basic Life Support from the American Heart Association Upon Hire Required.
- Certified Pediatric Nurse Preferred.
- Nursing Case Management Board Certification certification from a nationally recognized case management organization Preferred
- Children's is the very best for kids and the very best for your career!
- At Children's, we put YOU first so together, we can improve the life of every child!
Before you apply
Applying takes about a minute. These four things decide how fast it moves after that.
Your profile is current
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Two examples you can talk through
Not a portfolio — just two pieces of work where you can explain the decisions and what you'd change.
A number in mind
What you're on now and what would make you move. We negotiate better when we know both.
Your notice period
Employers plan around it, and it's the question that stalls offers most often.
Once you apply, someone reads it and calls you before anything reaches the employer — usually within two working days.
