The Nurse Care Manager assists in the care coordination and management of the complex healthcare needs for a diverse patient population. The incumbent will serve as teacher, planner, advocate, and navigator for the patients of Unity Health Care. This individual will be responsible for providing direct nursing care, performing nursing assessments, participating in the continuity of patient care and helping improve patient outcomes through systems processes and direct provision of clinical care.
· Develops a working, therapeutic relationship with patients.
· Assesses and evaluates problems related to chronic or acute conditions such as cardiovascular disease, diabetes, and asthma, as well as the socio and ecological barriers that impact the improvement of health and wellness.
· Develops effective treatment plans identifying, activating, and linking patients to appropriate care and established support systems (i.e., family, social, treatment programs, services, emergency assistance)
· Assists patients in following through with established treatment plans; Identifies and addresses any barriers effecting a patient's ability to adhere to treatment team
· Improves patient outcomes through the coordination and follow up of care.
· Collaborates with entire care team (Provider, Medical Assistant, social services/care support, registration and health information staff) to assure that the patient receives timely care and follow-up.
· Collaborates with other team members regarding the status of patients' social and mental health needs.
· Utilizes multi-modality educational concepts during nurse visits to help manage complex chronically ill patients; Nurse Visits include blood pressure follow-up, family planning education, and immunization compliance.
· Monitors patients use of health center services; Provides patient education and helps address barriers related to receiving adequate care, and addresses patient utilization of health systems in Washington DC.
· Assist with coordination of care following recent hospitalization.
· Executes and monitors data collection and reporting requirements for all institutional and federal regulations as required through an electronic or manual system.
· Participates in professional development opportunities and attends staff/team meetings as deemed necessary.
· Documents in medical records per policy and standards. Maintains accurate and up-to-date records in a timely manner.
· As allowable by the nursing scope of practice, assists with supervision and delegation of duties of other clinical staff members (LPNs, MAs).
· Must be able to take initiative, identify areas of clinical improvement and discuss plan of action with appropriate personnel.
· As allowable by the nursing scope of practice, performs routine nursing procedures such as intake, triage, injections, and emergency care.
· May facilitate home visits to patients unable to schedule appointments at the Health Center if appropriate.
· Performs other duties as assigned.
· Graduation from an accredited school of nursing.
· Current DC License; LPN and RN eligible to apply.
· Clinical expertise may include any of the following: emergency room, mental and behavioral health, women's health, pediatrics, infectious disease, community or public health, polypharmacy teaching, care coordination, discharge planning, and chronic disease care management.
· Additional work experience may include any of the following: teaching, health promotion, social and ecological determinants of health, monitoring and evaluation of health outcomes, working with diverse populations, family studies, and outreach; Professional skillsets including but not limited to communication, conflict resolution and management, and interprofessional teamwork.
· Current CPR Certification.
KNOWLEDGE & EXPERIENCE REQUIRED BY THE POSITION
· Ability to supervise and to work independently and in a team-oriented environment.
· Excellent interpersonal and written communication skills.
· Must be well organized, flexible and action-oriented.