Nurse Care Manager
: Job Details :

Functions as a liaison for patient/caregiver/family in navigating the continuum of care and serves as a patient advocate in inter-disciplinary meetings.Collaborates with the patient-centered medical home inter-disciplinary team including providers, pharmacists, dentists, behavioral health providers, chronic disease specialists, community health workers, and nurse/nursing support personnel to achieve patient outcomes.Interacts with patients, caregivers, provider teams and the community to achieve continuity of care, coordination of services, timely follow-up, and care planning.Identifies early risk factors, conducts ongoing health assessments, and develops and maintains accurate care records of each referred patient within the electronic health record.Collaborate with health plans, hospitals, and utilize internal reporting capabilities to identify patients who have a recent hospitalization or emergency department visit. Distributes patient follow-up to the Chronic Disease Specialists for outreach and appointment scheduling.Proactively identifies and addresses barriers to care. Maintain a current list of community agencies and resources to provide to patients, caregivers, and provider teams.Provides support services and/or appropriate referrals for patient, caregiver and family as recommended by the inter-disciplinary teams.Assures quality of care by adhering to evidenced-based guidelines; measures health outcomes against patient care goals; makes recommendations to the care team when necessary.Participates in the Quality Program through incident reporting and identifying opportunities forParticipate in the Compliance Program through fraud, waste, and abuse prevention, detection, and reporting; and protecting patient confidentiality under HIPAA.Participate in the Infection Control Program through following hand washing and Bloodborne Pathogen safety and exposure protocols.Other duties as