OverviewRegistered Nurse Care Manager - Stony Brook Family and Preventative Medicine, UFPCLocation: Stony Brook, NYSchedule: Full TimeDays/Hours: Mon - Fri 9 -5; Occ Sat (9-1) Salary Range: $99,806 - $110,145 (pay will be determined based on experience, preferred qualifications, and education) Our compensation philosophy aims to provide marketable compensation programs and to compensate employees based on relevant experience and education. Individual compensation discussions begin during the hiring process and may occur during job review and promotional opportunities. Salaries vary depending on experience, education and current market for the position. Human Resources determines the external and internal equitable salary for each employee. ResponsibilitiesSUMMARY: The Department of Family, Population & Preventive Medicine seeks an RN Care Manager to provide high-quality, individualized patient care utilizing professional nursing skills and knowledge. This role involves managing care coordination, maintaining Patient-Centered Medical Home (PCMH) certification, and ensuring compliance with reporting requirements. The RN Care Manager works closely with management, providers, and patients to optimize outcomes, reduce hospital readmissions, and address gaps in care. This role involves direct patient care, care plan development, overseeing care coordination teams, assisting in workflow implementation, and ensuring adherence to quality and performance standards in accordance with professional standards and organizational policies. The RN Care Manager will also support quality improvement projects and ensure compliance with HIPAA and OSHA guidelines. Job Duties & Essential Functions:
Supervision & Team Management: - Supervise the care coordination team and collaborate with the Director of Behavioral Health and outpatient behavioral health teams to implement processes that address care gaps.
- Manage the effectiveness of daily huddles by ensuring procedural information, care plans, and updates are disseminated efficiently.
- Recruit, onboard, and evaluate care coordination staff, and oversee performance improvement plans as necessary.
- Recruit, onboard, and evaluate nursing staff in conjunction with the RN Ambulatory Manager.
Care Coordination & Direct Patient Care: - Provide direct patient care, including conducting appropriate patient testing, administering medications and vaccines, and documenting care in the patient's treatment plan.
- Utilize physical assessment skills to evaluate patient needs, ensuring all patient care responsibilities are performed safely and in compliance with professional standards.
- Develop individualized care plans in consultation with treating physicians, including those for highly complex patients, and assist with social determinants of health such as transportation, unemployment, and food security.
- Provide patient education for chronic conditions such as asthma, hypertension, and diabetes and includes but is not limited to teaching patient's appropriate inhaler use, using a continuous glucose monitor (CGM), administering GLP-1 medications, and home blood pressure monitoring.
Care Management & Transitional Care: - Contact patients post-discharge from the emergency room to facilitate follow-up appointments and provide care re-education.
- Track care management patients in a daily spreadsheet, alerting staff and providers about upcoming care management appointments, and update care plans for chronic disease management.
Triage & Patient Communication: - Triage patient phone calls and messages from various sources, including the call center, patient portal, providers, and home care nurses, addressing medical complaints, symptom concerns, or urgent issues (e.g., labs reporting critical values) in conjunction with the RN Ambulatory Care Manager.
- Assist with resolving patient inquiries, and manage emergency situations that may require police, CPS, or EMS intervention in conjunction with the RN Ambulatory Care Manager.
Quality Improvement & Compliance: - Collaborate with the management team to review quality metrics, PCMH data, and customer service reports to identify and participate in quality improvement (QI) projects.
- Ensure adherence to institutional and insurance company quality measures for identifying care management needs and addressing care gaps.
PCMH Certification & Reporting: - Maintain PCMH certification by ensuring compliance with certification requirements and reporting standards.
- Review and summarize PCMH data, including patient surveys, appointment availability, and after-hours clinical advice, and prepare reports for PCMH certification renewals.
- Create and update PCMH policies and procedures based on new certification requirements and institutional guidelines.
Data Management & Documentation: - Maintain accurate documentation of care coordination and patient interactions in the electronic medical record (EHR).
- Run, review, and summarize PCMH reports, patient surveys, and clinical advice reports, ensuring that all data is timely and relevant for care coordination and PCMH certification.
Education & Staff Training: - Train new and existing staff on patient care duties, PCMH policies, and care coordination processes to ensure adherence to organizational standards.
- Develop and implement training materials for clinical staff related to PCMH policies and care management practices.
Professional Conduct & Compliance: - Follow HIPAA and OSHA guidelines and demonstrate courteous, professional behavior when dealing with patients.
- Exhibit high-level problem-solving and analytical skills, while maintaining ethical standards.
- Be self-directed, motivated, and able to multitask in a fast-paced, high-productivity environment with accuracy.
Other Responsibilities: -
- Perform additional duties as assigned by management, including resolving patient inquiries, managing escalated situations, and ensuring a seamless patient experience across all care settings.
QualificationsRequired Qualifications:
- Associate's degree in Nursing. (New York State BSN in 10 Law - Must attain Bachelor's in Nursing or higher within 10 years of initial licensure. Current RNs, as well as those currently enrolled or pending acceptance into a program preparing registered nurses effective date of this act (which is Dec. 19, 2017) are grandfathered in.)
- 3 years of nursing experience.
- Basic Cardiac Life Support (BCLS) required.
- Current registration to practice as a Licensed Registered Nurse in New York State.
- Must have excellent communication skills.
Preferred Qualifications:
- Bachelor's degree in Nursing.
- Experience with care coordination methods preferably in an academic practice and/or PCMH primary care, Care Management experience.
- Experience with Transitional Care Management.
- Advanced Cardiovascular Life Support (ACLS).
- 1 year inpatient experience; 5 years outpatient experience.
Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to communicate with patients, staff and medical providers. The employee must be able to exchange accurate information in these situations. This position is active and requires the employee to constantly move about in the office to assist patients, staff and medical providers. Any additional physical demands will be outlined and provided by management. The responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of CPMP. StaffCo is a Professional Employer Organization, commonly referred to as a PEO, duly organized and registered under the New York Professional Employer Organization law. StaffCo and SUNY have entered into a professional employer agreement under which StaffCo is the employer of Stony Brook Clinical Practice Management Plan employees and responsible for all aspects of employment, including hirings, promotions, disciplines, terminations, the day-to-day direction and supervision of work, as well as labor relations and collective bargaining. StaffCo is fully responsible for providing all payroll and human resources services, including the payment of wages, collecting and reporting payroll taxes and maintaining any and all employee benefits. SUNY Stony Brook Hospital is responsible for the operation of the hospital and provision of health care and is the co-employer as is necessary to conduct its responsibilities and for related licensure, regulatory or statutory requirements and obligations. Given StaffCo's employment responsibilities, it is deemed the employer for employment and labor law purposes. Thus, the employees are private sector employees of StaffCo, not public sector employees of SUNY. The private sector nature of the StaffCo employees has been approved by NYS Civil Service and upheld in a decision by the US National Labor Relations Board. CPMP provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, gender identity or expression, or any other legally protected status. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall and transfer, leaves of absence, compensation and training. CPMP expressly prohibits any form of workplace harassment based on race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, gender identity, or any other legally protected status. Improper interference with the ability of CPMP's employees to perform their job duties may result in discipline up to and including discharge.